Proximal Femoral Fractures Sudhir Babhulkar, DD Tanna
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Obstetric Vasculopathies
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Anatomychapter 1

The proximal femur consists of the femoral head, neck femur, intertrochanteric and subtrochanteric regions. The femoral head articulates with the acetabulum to form a ball and socket hip joint. The femoral head is a round structure of cancellous bone sheathed in the articular cartilage, and is characterized by a dense meshwork of trabecular bones which absorbs and evenly distributes weight to the femoral neck and proximal femur. The femoral head is not a perfect sphere, and the joint is congruous only in the weight-bearing position.1, 2 The size of the femoral head varies in proportion to the body mass and ranges roughly from 38 to 58 mm in diameter and is covered by articular cartilage with an average thickness of 3 to 4 mm.2
The femoral neck lies between the femoral head and the intertrochanteric line anteriorly and the intertrochanteric crest posteriorly. The femoral neck forms an angle with the femoral shaft in the anteroposterior plane ranging from 125° to 140° and an angle of anteversion of 10° to 15° in the lateral plane. In 1938 the internal trabecular system of the femoral head was described by Ward (Figs 1.1A and B). The cancellous bone of the femoral neck has a special trabecular arrangement which is organized into medial and lateral trabecular systems. The orientation is along the line of stress, and thicker lines come from the calcar and rise superiorly into the weight-bearing dome of the femoral head.
The forces acting in this arcade are largely compressive. Lesser trabecular patterns extend from the inferior region of the foveal area across the head and superior portion of the femoral neck into the trochanter and lateral cortex. The presence of osteoporosis is important, especially when the patient is being considered for internal fixation, because the ability of the osteoporotic bone to hold an internal fixation device is poor and such bone can affect the treatment alternatives. The trochanteric region is an area of high stress concentration that is subject to multiple deforming forces, making anatomic reduction of a fracture difficult. The intertrochanteric region of the proximal femur consists of greater and lesser trochanters and it represents a transition zone from the neck of 2the femur to the shaft.
Figs 1.1A and B: (A) The arrangement of tensile and compression trabeculae; (B) Ward's triangle
This area is primarily characterized by a dense network of trabecular bone which serves to transmit and distribute the stress, similar to the neck of the femur. The major muscles of the gluteal region are inserted into the greater trochanter; gluteus medius, gluteus minimus and short external rotators, whereas the iliopsoas muscle is inserted into lesser trochanter. The greater trochanter is the site of insertion of the powerful hip abductors, gluteus medius and minimus and short external rotators of the hip (Fig. 1.2). The lesser trochanter is a posteromedial bony eminence at the inferior aspect of the intertrochanteric ridge that provides attachment to the iliacus and psoas hip flexors (Fig. 1.2). These muscles act on the proximal fragment of a subtrochanteric femur fracture, resulting in a flexed, abducted, and externally rotated position. The distal fragment is shortened and adducted by the hamstrings and hip adductors, resulting in an overall varus and anterior apex deformity at the fracture site. The calcar femoral, a dense bone which extends from the posteromedial aspect of the proximal femoral shaft to the posterior part of the femoral neck, forms a strong strut on the inferior part of the femoral neck and intertrochanteric region and serves a strong conduit for the weight transfer. The calcar femorale is thicker medially and gradually thins as it passes laterally.
The subtrochanteric region extends from the lesser trochanter to an area 5 cm distal, and consists primarily of thick, dense cortical bone. This is an area of high stress concentration, with large compressive forces medially and tensile forces laterally. The dense cortical bone permits efficient transmission of loads.
The hip capsule is attached proximally to the acetabulum and distally to the medial side of the greater trochanter, intertrochanteric line anteriorly, superiorly and medial to the lesser trochanter, and to the base of the femoral neck posteriorly. The entire anterior aspect of the femoral neck and proximal 3two-thirds of its posterior portion lie within the capsule.
Fig. 1.2: Anatomy around the trochanteric region
Fig. 1.3: The vascularity around the hip joint
Three prominent ligaments, iliofemoral, ischiofemoral, pubofemoral and one minor ligament—zona orbicularis conjoins with the hip joint capsule.
The hip joint capsule is a strong fibrous structure that encloses the femoral head and most of its neck. The capsule is attached anteriorly at the intertrochanteric line; posteriorly, however, the lateral third of the femoral neck is outside the capsule. That portion of the neck that is within the capsule has essentially no cambium layer in its fibrous covering to participate in the peripheral callus formation during the healing process. Therefore, healing of the femoral neck area is dependent on endosteal union alone. The blood supply to the femoral head and neck is complex. The femoral head derives its blood supply from the two largest tributaries of the profunda femoris. Medial and lateral femoral circumflex arteries send branches that anastomose to form an extracapsular arterial ring at the base of femoral neck (Figs 1.3 to 1.5). From this arterial ring, it sends ascending cervical arteries 4called as retinacular arteries which pierce the hip joint capsule and traverse along the neck of the femur deep to the synovial membrane.
Fig. 1.4: Anterior view of coronally sectioned hip joint
Figs 1.5A and B: Blood supply of the femoral head (A) Anterior view; (B) Posterior view
There are four major retinacular arteries, out of which the lateral retinacular artery is the most important blood supply to the femoral head and neck. The femoral head also receives blood supply from the artery of the ligament of head of femur, which branches from the obturator artery.
 
References
  1. Cathcart RF. The shape of femoral head and preliminary results of clinical use of anonspherical hip prosthesis. J Bone Joint Surg Am 1971;53:397.
  1. Hoaglund FT, Low WD. Anatomy of the femoral neck and head, with comparative data from Caucasians and Hong Kong Chinese. Clin Orthop 1980;152:10–6.

Epidemiology, Mechanism of Injury and Diagnosischapter 2

 
Epidemiology
The incidence of hip fractures is steadily increasing worldwide. A recent study predicted that the number of hip fractures in the elderly will double or triple within the next 20 years. Various factors affect the risk of hip fractures, including age, sex, ethnicity, bone mass, nutrition, height, weight, use of medicines, etc.
Virtually every study cites age as an important risk factor. Patients younger than 50 years sustain only 2 to 3 percent of hip fractures.1 However, lately there has been a rise in the number of young, active adults with hip fractures seen after vehicular automobile accidents. This is commonly seen as a result of the use of smaller automobiles with lower dashboards where a driver occupies such a position that after collision, the forces culminate in proximal femoral fractures.
Hip fractures are frequently seen in females. Most investigators have found a female-to-male ratio of 2:1 in patients over 65 years of age. Melton3 attributed the disparity in hip fracture risk to the lower bone mass in females, lower bone density and higher frequency of falling.
Medical comorbidities, hypertensives, diabetics, patients on medication for diseases affecting mental status, sensory perception, balance and locomotion are associated with an increased risk of hip fractures. Cerebrovascular episodes such as stroke have been associated with an increased risk of hip fractures. Any medical condition that results in accelerated bone loss, like diabetes and thyroid dysfunction, increases the risk of hip fractures. Similarly, patients with arthritis, parkinsonism, diabetes and epilepsy are associated with greater risk of hip fractures. Patients taking long-acting medication may have side-effects including confusion, ataxia, dizziness and impaired coordination and are at a higher risk for hip fractures.
Individuals who have previously sustained a fragility fracture are at increased risk for hip fracture. Persons who have suffered a prior hip fracture are 1.6 times more likely than others to sustain a second, contralateral hip fracture. There is a higher prevalence of prior fragility fractures (like vertebral fractures, distal radius or proximal humerus fractures), in patients who have sustained intertrochanteric fractures.26
Bone density exhibits a strong negative correlation with fracture risk; bone strength and density decrease with advancing age, resulting in an increased risk of fracture. The hip fracture risk increases two to three times for each standard deviation reduction in bone mineral density. Lack of physical activity is a risk factor for hip fracture since it results in a lowered bone density, reduced muscle mass, and reduced muscle strength. Similarly, inadequate dietary calcium intake increases the risk of hip fractures. Malnutrition is seen in the elderly population and it increases the risk of hip fractures. It results in impaired muscular coordination, and reduces the strength, both of which increase the chances of a fall. Malnutrition reduces the thickness of subcutaneous tissue covering the hip and trochanteric area, thus reducing the force required to cause hip fracture.
The relationship between health status, including the number of comorbidities and activity level is controversial.
The degree of osteoporosis influences the fracture type. Intertrochanteric fractures are more common in severe osteoporotic women.
 
Mechanism of Injury
Most of the hip fractures in the elderly are sustained by a fall while walking or standing and in the bathroom. As a result of the fall there might be a direct impact on the hip sustaining the fracture. A fall from a standing height in a typical elderly person generates at least 16 times the energy necessary to fracture the proximal femur. However, the mechanism of fall is important in determining whether a fracture will occur after a fall.
Four factors are important in determining whether a particular fall will result in hip fracture:
  1. If the fall is direct and the person lands on or near the hip
  2. Inadequate protective reflexes to absorb the energy of fall
  3. Inadequate shock absorbers like muscles and fat around hip
  4. Insufficient bone strength at the hip.
The person must land on or near the hip for the energy of the fall to be transmitted to the hip. Direct fall onto the lateral thigh or onto the greater trochanter is more likely to cause hip fracture. Such falls are more likely to occur when an elderly person is standing or walking slowly, because their reaction times are longer and muscle strength less. The protective responses of elderly persons tend to be too little and too late to prevent the fall. Similarly, muscles surrounding the hip and fat can absorb a large amount of energy from an impact, and serve as protective tissue, which is reduced in the elderly population.
Cyclic mechanical stresses can also result in a hip fracture, fatigue fracture or stress fracture. It usually occurs secondary to repetitive mechanical stress or loading. In elderly people where bone fatigue strength is lowered because of osteoporosis or other disease states, fewer loading cycles can lead to 7proximal femoral fracture, which is called insufficiency fracture. This stress fracture of the proximal femur, results from alterations of the normal stress and strain pattern of the proximal femur, secondary to increased mechanical loads or muscle fatigue. These fractures may not be preceded by a fall.
In conclusion, fractures of the proximal femur can result from a fall, intrinsic factors or cyclical mechanical loading (insufficiency fractures).
 
Diagnosis
The clinical presentation of proximal femoral fractures varies widely depending upon the type, severity and the cause of fracture. Patient with displaced fracture just cannot stand and attempted movements of the hip are painful and restricted. Patients with displaced fractures cannot stand, bear weight nor can they walk. Patients with impacted fracture or undisplaced fractures, may be ambulatory with minimal pain. Most hip fractures in the elderly are the result of an accidental fall, whereas in young adults they are more often caused by high-energy trauma following motor vehicle accidents. In a patient in whom trauma is not the cause, pathologic fracture should be considered, especially in a sedentary person with no history of injury. It is important to obtain a careful medical history of comorbidities, since it can affect both the treatment and prognosis. To establish a reasonable management protocol one must obtain a detailed history of the pre-injury status of the patient. Physical examination of the limb shows the amount of clinical deformity, which reflects the degree of fracture displacement. In displaced fractures, usually, the limb exhibits the classical presentation of externally rotated limb with shortening. There is marked tenderness around the hip and greater trochanter, and it may be associated with ecchymosis. Attempted movements of the hip are very painful and should be avoided.
Patient should be subjected to standard X-ray examination, which includes X-ray pelvis with AP both hips and lateral view. AP pelvis X-ray allows comparison of the involved side with the contralateral side, which can diagnose undisplaced and impacted fractures. The lateral X-ray is necessary to look for posterior comminution in the femoral neck and proximal femur. Though lateral view is helpful, it is difficult to obtain in a painful patient and hence should be studied mainly under anesthesia. An internal rotation view of the injured hip must be done to see the full length of the neck of the femur, which may be necessary to identify undisplaced or impacted fracture neck femur. When a hip fracture is suspected but not apparent on standard radiographs, it may be necessary to obtain computed tomography (CT), radioisotope bone scans or magnetic resonance imaging (MRI). Usually it takes two to three days for bone scan to become positive, whereas MRI may be more accurate in identifying occult fractures of the hip.38
 
References
  1. Melton JL, Ilstrup DM, Riggs BL, Beckenbaugh RD. Fifty-year trend in hip fracture incidence. Clin Orthop 1982;167:131–1.
  1. Hedlund R, Lindgren U, Ahlbom A. Age and sex-specific incidence of femoral neck and trochanteric fractures: An analysis based on 29,538 fractures in Stockholm country, Sweden, 1972-1981. Clin Orthop 1987;222:132–9.
  1. Melton JL. Hip fractures: A worldwide problem today and tomorrow. Bone 1993;14:S1–S8.

Principles of Treatmentchapter 3

The primary aim of fracture management is to return the patient to his pre-injury status. Conservative treatment has a very limited role in a few, selected, non-ambulatory patients who experience minimal discomfort from this injury. These patients should be quickly mobilized to avoid the complications of prolonged decumbency: Decubitus ulcers, pulmonary complications, urinary tract infection, and thrombophlebitis.
All patients of proximal femoral fractures need hospitalization. It is preferable to maintain the leg in slight flexion and external rotation with a pillow underneath the knee, in the position of comfort. Traction is not necessary if surgery is planned early. If the patient has pain, which he/she cannot tolerate, immediate epidural analgesia is a good option. The same catheter can be used when the patient is taken for surgery in one or two days’ time. The fracture surgery should be performed within one or two days after stabilizing comorbid medical disorders. Regional anesthesia has been found to be safer as compared to general anesthesia in the elderly population. Studies have demonstrated the efficacy of spinal and epidural anesthesia, and the use of pneumatic foot pumps in the prophylaxis of deep vein thrombosis and pulmonary embolism. Patients of proximal femoral fractures are at increased risk for thrombophlebitis.
 
Method of Thromboprophylaxis
Two approaches are considered to prevent fatal pulmonary embolism: early detection of subclinical venous thrombosis by screening high-risk patients and primary prophylaxis by administering low molecular weight heparin and other drugs or by physical methods which are effective in preventing deep vein thrombosis like using elastic stockings, and intermittent pneumatic compression. Use of aspirin in conjunction with intermittent pneumatic compression pump is a safe and effective method of thromboprophylaxis. The only reason to avoid immediate postoperative chemical prophylaxis is the oozing which might occur.10
We feel that chemical prophylaxis be withheld for two or three days post-surgery and then started; if oozing occurs after starting prophylaxis then drugs should be stopped temporarily. Physical antiprophylaxis should be continued till the wound has stabilized. Chemical prophylaxis can be resumed once the wound has stabilized.

Femoral Head Fractureschapter 4

Femoral head fractures are always due to high-energy trauma. Commonly, it is a dashboard injury with flexed-adducted hip and flexed knee, and is frequently associated with dislocations of the hip joint. It is a rare injury and hence individual surgeons lack vast experience in the management of these fractures. Traumatic dislocation of the hip with associated femoral head fracture was first described by Birkett in 1869.1 Almost a century later, a classification of these injuries was proposed by Pipkin in 1957,2 whose name has since been associated with this lesion. The treatment guidelines have evolved on the basis of a relatively limited series of studies. Emergency reduction of the hip is imperative, regardless of the type or extent of the fracture. Once reduction is accomplished, further evaluation, including computed tomography (CT), is indicated to assess the congruity and stability of the joint. The outcome of this injury is not uniformly good, since associated complication rate is high. Poor comparison of treatment regimens, lack of uniformly applied classification scheme, and inadequate functional results, has led to lack of any uniformity in the line of treatment. Controversy exists regarding many aspects of the treatment of these fractures.
 
Mechanism of Injury
Traumatic dislocations of the hip are high-energy injuries that frequently occur with fractures of the femoral head. Usually, a dashboard impact of the knee during high-speed motor vehicle accident results in femoral head fractures. The commonly observed associated injuries are hip dislocation, fracture femoral neck, fracture acetabulum, pelvic ring injury, and femoral shaft fractures. Avulsion fracture of the femoral head occurs via the attachment of the ligamentum teres, which remains attached to the inferomedial fragment and is retained in the joint. There may be shearing force of the injury resulting in severe force of the femoral head against the acetabular rim, which may lead to indentation fracture.
 
Injury Profile
Commonly, femoral head fracture is seen following motor vehicle accident and the clinical presentation may vary depending upon whether the patient 12presents immediately after the accident or is referred from another center. Hence, patient may present as fresh or neglected fracture of femoral head. Patient may belong to the group of polytraumatized patients and may have head injury and other associated injuries. Patient may have associated local injury like ipsilateral acetabulum fractures or fracture neck femur. The associated dislocation of hip is commonly posterior; however, there might be central or anterior (iliac or obturator) dislocation.
 
Classification
Femoral head fractures are infrequent injuries and they are usually associated with dislocation of the hip joint. Posterior dislocation of the hip was classified in detail by Thompson and Epstein 19513,4,5 in which Type V was associated with femoral head fracture. Similarly, posterior dislocation of hip was also classified by Stewart and Milford in 1954,6 where Type IV described association of fracture of femoral head, which Pipkin2 (1957) sub-classified into four types.
 
Thompson and Epstein Classification
Type I:
Posterior dislocations without fracture or with no more than a minor fracture.
Type II:
Posterior dislocation with a large single fracture of the posterior acetabular rim.
Type III:
Posterior dislocation with a comminuted fracture of the posterior rim of the acetabulum with or without a major fragment.
Type IV:
Posterior dislocation with a fracture of both the acetabular rim and floor.
Type V:
Posterior dislocation with fracture of the femoral head, with or without other fractures.
After reduction, many of the Type IV lesions had the appearance of central fractures with medial displacement of the femoral head. The extent and comminution of the accompanying fractures occasionally made precise classification difficult.
 
Stewart and Milford Classification
Type I:
Simple dislocation without fracture.
Type II:
Dislocation with one or more rim fragments but with sufficient socket to ensure stability after reduction.
Type III:
Dislocation with fracture of the rim producing gross instability.
Type IV:
Dislocation with fracture of head or neck of the femur.
13
 
Pipkin Classification (Figs 4.1A to D)
Pipkin's classification was directed towards the fracture of the femoral head and was more prognostic, but it did not include the association with anterior hip dislocations. The deficiency of anterior hip dislocations and lack of comments on the biomechanics, especially regarding the hip stability led Brumback et al.7 to develop the most comprehensive system of classification of these injuries. The Pipkin classification system does not differentiate the problems associated with either anterior or central fracture dislocations. The Brumback (1987) classification system is more detailed and addresses specific problems associated with these two subsets.
 
Brumback Classification (Fig. 4.2)
  1. Posterior fracture dislocation with inferomedial fragment
    I A–Minimal/No acetabulum injury
    I B–Significant acetabulum injury, stable after reconstruction
    Figs 4.1A to D: X-rays showing types of fracture femoral head as per Pipkin's classification (1957)
    14
    Fig. 4.2: Brumback's classification
  2. Posterior fracture dislocation with superomedial fragment
    II A–Minimal/No acetabulum injury
    II B–Significant acetabulum injury, unstable
  3. Dislocation of hip (unspecified direction) + fracture femoral neck
    III A–Without femoral head fracture
    III B–With femoral head fracture
  4. Anterior dislocation with femoral head fracture
    IV A–Superolateral indentation
    IV B–Transchondral/shear # of weight-bearing surface
  5. Central fracture dislocation with femoral head fracture.
 
Investigations
X-rays, CT and CT 3D reconstruction are very informative, and must be done for preoperative documentation and to decide the line of treatment as these fractures will need long-term, repeated treatment and hence reference to original X-rays and CT scan will be needed. After reduction of the dislocation, plain X-ray and CT scan are also mandatory to see the exact reduction and the pattern of the fracture, for definitive line of treatment.
 
Treatment Options and Management Protocol
Once the patient is hemodynamically stable, early reduction of dislocated hip is necessary. The primary goal is rapid concentric reduction of femoral head within the stable acetabulum that is free of soft tissue debris or bone fragments. Most of the patients are young, hence acute reduction and reconstruction of the femoral head should be the treatment of choice. Failure to achieve concentric, and stable closed reduction should end up in immediate open reduction.18 The postreduction CT is helpful to assess the 15presence of acetabular fracture, presence of fracture neck femur, adequacy of reduction and presence of loose body. There are a few definite indications of urgent open reduction, especially when there is postreduction joint asymmetry of hip, or progressive sciatic nerve palsy, and if femoral head or acetabular fragment is displaced more than 2 mm.
Controversy still remains regarding the treatment of femoral head fractures.915 It is generally accepted that Pipkin Type III fractures (fractures of femoral head and associated ipsilateral fracture neck femur) and Type IV (fracture femoral head with fracture acetabulum) should best be treated by operative reduction and stabilization.11,12
 
Historical Controversy of Operative Reduction and Surgical Approach
In femoral head fractures, free or nonreduced fragments that remain after reduction must be excised or reduced and stabilized to avoid early post-traumatic arthrosis. Historically, recommendations have included excision of large fragments, up to one-third of the femoral head. However, because the entire acetabulum is involved in weight-bearing, it is recommended that any fragment that is amenable to fixation should be rigidly fixed and that small fragments can be excised. Controversy has persisted regarding the optimal surgical approach for fixation of femoral head fractures associated with a posterior hip dislocation.
Several different methods have been advocated, initially, a posterior Kocher-Langenbeck approach9 was recommended, but more recently a direct anterior Smith-Petersen approach has been advocated. The Kocher-Langenbeck approach is used to address a large posterior wall acetabular fragment and was initially thought to avoid damage to the anterior vessels that are the major vascular supply to the femoral head. However, visualization of anterior head fragments through this approach is extremely limited and adequate reduction and fixation of the femoral head is unpredictable. The Smith-Petersen approach does provide direct access to the anterior surface of the femoral head, but visualization of the entire head is often impaired. An anterior approach may be feasible for excision of comminuted fragments and debris, but the Smith-Petersen approach often does not allow adequate exposure to anatomically reduce extensive femoral head or posterior acetabular fractures.
Epstein4,5 wrote in his paper–“Anterior approaches for open reduction of posterior dislocations of the hip are contraindicated. It is likely that most, if not all, of the blood supply to the hip joint is damaged when a posterior dislocation occurs. A surgical procedure that embarrasses whatever blood supply remains is therefore inadvisable.” Because of the unaffected anterior hip capsule in posterior dislocation of the hip with associated femoral head fracture, Epstein strongly advocated posterior Kocher-Langenbeck approach for surgical stabilization, since the anterior approach requires anterior capsulotomy to visualize femoral head fragment which increases 16the possibility of osteonecrosis of the femoral head. Whereas Hansen9 has advocated an anterior Smith-Petersen approach for reduction and fixation, because with a posterior hip dislocation the femoral head fragments are anterior, thus facilitating the open reduction and internal fixation.
Recently, a surgical hip dislocation technique has been described for acetabular fractures and deformities of the proximal femur.1618 Surgical dislocation of the hip as described by Professor R Ganz clearly provides significant advantages over traditional approaches for fixation of the femoral head, including a complete visualization of the fracture, documentation of the femoral head blood supply, joint debridement, and an anatomic reduction of the weight-bearing surfaces. All are helpful in increasing the chance of a good outcome. Surgical dislocation and fixing the fragment has now become the standard surgical approach.
The outcomes of this injury are not uniformly good, since the associated complication rate is very high, which includes avascular necrosis, post-traumatic arthrosis, heterotopic ossification,2831 malunion, and progressive sciatic nerve dysfunction, hence every possible precaution should be taken to avoid such complications. Early postoperative rehabilitation should be done along with ambulation, late weight-bearing and regular follow-up monitoring to detect osteonecrosis and arthrosis.32 Indomethacin should be given as prophylaxis to minimize or prevent heterotopic ossification.31
 
Treatment Protocol
 
Pipkin Type I
The fracture line is caudal to the fossa of the femoral head and fractured fragment is small, placed inferomedially—this can be left alone.
If the patient reports early, Type I fracture could be treated conservatively by closed reduction without stabilization of the tiny femoral head fragment (X-rays of a patient of Pipkin Type I treated conservatively, Figures 4.3A to C, confirmed by CT). However, if patient reports late with persistent fracture, dislocation surgery for reduction of dislocation and excision of small fragment is necessary, as seen in Figures 4.4A to E.
Figs 4.3A to C: Pipkin Type I fracture treated conservatively by closed reduction—follow-up three years
17
Figs 4.4A to E: Two-month-old persistent Pipkin Type I fracture dislocation seen in top X-rays, treated by open reduction and excision of small femoral head fragment, postoperative X-ray seen in bottom X-rays
 
Pipkin Type II
In a Type II injury, the fracture line is cephalic to the fossa of the femoral head and head fragment is large, attached to the ligament, vascular, and at times closed manipulation can produce an anatomical reduction of the fracture of the head.
If the hip cannot be reduced by manipulation, or if there is poor reduction of femoral head fracture, open reduction should be performed, followed by fixation of femoral head fracture with Herbert screw or ordinary screw with pushing and submerging the screw head inside the articular surface.
However, before open reduction is attempted, a CT scan of the hip joint should be urgently performed (Figs 4.5A to D). Fixation of the femoral head fragment by screw may be necessary, especially in young patients (Figs 4.6 to 4.10). However, in the elderly age group with severely comminuted femoral head fracture, primary total hip joint replacement is a better choice. Early reduction of dislocated hip enhances early and complete recovery of blood supply to the femoral head, but the delay of reduction of dislocated hip beyond 12 hours or longer does not benefit the rate and extent of the circulatory recovery of the femoral head.
 
Pipkin Type III
There is fracture of femoral head Type I or II along with fracture neck femur. There is marked instability, and vascularity is impaired. This type of injury can result while attempting the closed reduction for Type I or II injury (iatrogenic cause).18
Figs 4.5A to D: Young patient with Pipkin Type II injury, fracture femoral head with posterior dislocation with sciatic nerve palsy
Figs 4.6A to D: Postoperative X-rays at three months, and five months, sciatic nerve recovered in 12 months
19
Figs 4.7A and B: X-ray, 10 years follow-up, developed osteonecrosis, but functionally with good range of movements
Figs 4.8A to E: Young artist with Pipkin Type II injury seen on plain X-ray and CT
20
Figs 4.9A to C: Operative scar and range of movements of the same patient (Figs 4.8 and 4.9) at three months
Figs 4.10A to C: Immediate postoperative X-ray of the same patient and follow-up X-ray at three months
21
In Type III fractures (Figs 4.11A and B), there are three elements of injury, dislocation of hip, fracture femoral head and fracture femoral neck, which at times might be iatrogenic. Surgical treatment is mandatory for fixation of fracture neck femur and stabilization of femoral head fragment or one may consider total hip joint replacement.2225, 2733
 
Pipkin Type IV
There is fracture of femoral head Type I or II along with fracture of the acetabulum. In Type IV fractures (Figs 4.12 and 4.13), there are three elements of injury: Dislocation of hip, fracture femoral head and fracture of the acetabulum. Surgical treatment is mandatory for fixation of fracture acetabulum and stabilization of femoral head fragment.
Management: Treatment options include nonoperative treatment. One may try closed reduction, if the acetabular rim is stable or excision of small fracture fragment may be required. However, open reduction and fixation of acetabulum fracture and femoral head is commonly required (fixation or excision of small fragments).
 
Brumback Indentation Fracture
There is localized depression due to the impaction of the femoral head during the shearing force of the injury. It usually involves the weight-bearing area of the femoral head, where part of the femoral head is crushed and compressed leaving a big defect and causing deformation of the articular surface of the femoral head as seen in Figures 4.14A and B.
Management: Usually closed or open reduction of associated fracture dislocation and stabilization is required. However, once in a while one can consider rotational osteotomy of the femoral head if a large surface area of the femoral head is affected.
Figs 4.11A and B: X-ray and CT showing Pipkin Type III injury
22
Figs 4.12A to E: X-ray showing Pipkin Type IV injury with entrapment of fragment in the acetabulum seen on plain X-ray and CT
Figs 4.13A and B: Photographs showing entrapped acetabular fragment in the hip joint with small chip fragment of femoral head
23
Figs 4.14A and B: X-ray showing femoral head shear fracture with dislocation, prereduction and postreduction X-rays
Figs 4.15A and B: (A) Preoperative picture showing proposed Kocher-Langenbeck incision; (B) Kocher-Langenbeck incision showing exposure of fascia lata
Operative technique of surgical dislocation of the hip: After necessary anesthesia patient is placed in the lateral decubitus position on the operation table. A Kocher-Langenbeck incision is made and the fascia lata is split in the same line (Figs 4.15A and B). The limb is rotated internally and the posterior border of the gluteus medius is identified. An incision is made from the posterosuperior edge of the greater trochanter extending distally to the posterior border of the ridge of the vastus lateralis.
A flip trochanteric osteotomy with a maximum thickness of about 1.5 cm is made along this line with an oscillating pneumatic saw.1618 At its proximal end, the osteotomy should exit just anterior to the most posterior insertion of the gluteus medius (Figs 4.16 and 4.17). This preserves and protects the profundus branch of the medial femoral circumflex artery, which becomes intracapsular at the level of the superior gemelli muscle. The greater trochanteric fragment is mobilized anteriorly with its attached gluteus medius superiorly and vastus lateralis inferiorly. The most posterior fibers of gluteus medius are released from the remaining trochanteric base and also the part 24of the fibers of the tendon of piriformis.
Figs 4.16A and B: (A) Operative picture showing proposed incision for flip trochanteric osteotomy; (B) Exposures of capsules and muscles posteriorly—gluteus minimus and pyriformis after osteotomy
Figs 4.17A and B: (A) Diagrammatic representation of the flip trochanteric osteotomy of the greater trochanter; (B) Exposures of capsules and muscles posteriorly—gluteus minimus and pyriformis
With the leg flexed and externally rotated the tendon of piriformis becomes visible. The inferior border of gluteus minimus is separated from the relaxed piriformis and underlying hip capsule. The constant anastomosis between the inferior gluteal artery and medial femoral circumflex artery which runs along the distal border of the piriformis muscle and tendon is preserved. Similarly, care has to be taken to protect the sciatic nerve, which passes inferior to the piriformis into the pelvis. The gluteus minimus is retracted anteriorly and superiorly, which completely exposes the hip capsule.
The capsule is now incised sharply in a Z-shaped configuration along the anterolateral axis of the femoral neck (Fig. 4.18A). The incision is turned 90° to course distally along the reflection of the anterior capsule just before it reaches the anterior border of the piriformis. The capsulotomy must remain anterior to the lesser trochanter in order to avoid damage to the 25main branch of the medial femoral circumflex artery, which lies just superior and posterior to the lesser trochanter.
Figs 4.18A and B: (A) Z-shaped capsulotomy of the hip; the external rotators are kept intact; (B) Diagram showing flexed and externally rotated hip with leg brought over the front of the operating table where femoral head is dislocated and is completely visible
Medially, the previous femoral neck capsular incision should be extended proximally toward the acetabular rim and turned posteriorly parallel to the labrum up to the retracted piriformis tendon. The hip now can be dislocated by maneuvering the leg into flexion and external rotation, which exposes the entire femoral head. Sometimes ligamentum teres may need excision to achieve complete dislocation. With the manipulation of the leg, the surgeon now has a 360° access to the femoral head and also the acetabulum. For complete visualization and inspection of the acetabulum three retractors are used. Now the labrum can be inspected along with complete visualization of the articular surface of the acetabulum and femoral head (Fig. 4.18B). Small fragments of the femoral head, especially caudal to the fovea, can be excised (Fig. 4.19A). For sizable fragments the fracture femoral head should be anatomically reduced and rigidly fixed by headless screws or Herbert screws (Figs 4.20A to D). The head fragment should be fixed with lag effect from nonarticular entry point. Often the fixation should be augmented by an additional lag measuring 2.5 or 3.5 mm entering from the nonarticular regions to capture the fragments (Fig. 4.19B). Subsequently, fixation of the associated fracture acetabulum or neck femur can be performed simultaneously. After fixation of both the fractures now the hip may be relocated and put through a full range of movements in order to look for areas of impingement. Reduction of hip can be easily achieved by manual traction on the flexed knee and internal rotation. Copious irrigation of the wound should be performed and suction drain be kept. The capsule of the hip should be repaired but without any tension on retinacular vessels. The greater trochanter is reattached and fixed by 3.5 mm cortical screws, two to 26three in number (Figs 4.20 to 4.23).
Figs 4.19A and B: (A) Diagram showing complete exposure of acetabulum for removal of small fragments; femoral head can be seen completely for fracture reduction and fixation by screws; (B) Postoperative X-ray showing perfect anatomical reduction
The operative wound is closed in layers. Surgical dislocation allows fixation of both the fractures concurrently through a single approach and direct visualization of the articular surfaces of both femoral head and acetabulum, allowing anatomic reduction, and avoiding intra-articular prominent instrumentation.27
Figs 4.20A to D: (A and B) Operative picture showing complete surgical dislocation of hip, exposing the dislocated femoral head and piece of fracture femoral head lying in the acetabular cavity; (C) Fracture reduction and fixation and temporary fixation by K-wire; (D) Perfect anatomical reduction and fixation by 3 Herbert's headless screws
Figs 4.21A to D: (A and B) X-ray pelvis anteroposterior and hip lateral view (same patient as in Figs 4.20A to D), showing dislocation of hip with fracture femoral head; (C and D) CT scan showing fracture femoral head with dislocation
28
Figs 4.22A to C: (A) X-ray pelvis showing fracture femoral head with dislocation view (same patient as in Figs 4.20A to D); (B and C) X-ray pelvis anteroposterior and Dunn's view, showing reduction of fracture dislocation of hip with fixation of fracture femoral head by 3 Herbert's screw and fixation of osteotomy by two screws
 
Discussion
The type of surgery required for the fracture of femoral head is:
  1. Open reduction of both fracture and dislocation
  2. Open reduction of dislocation after internal fixation of fracture or vice versa
  3. Closed reduction and subsequent excision or fixation of lesser fragment
  4. Salvage procedure—prosthetic replacement/ total hip joint replacement.33
There are many controversies and debatable issues with variable opinions regarding whether closed reduction should be attempted or straight primary open reduction should be performed, what should be the surgical approach for internal fixation (Anterior vs Posterior approach)1618, 20, 22 and whether the fragment should be fixed or excised.
 
Results
The results of the treatment are best assessed by the Thompson and Epstein criteria by clinical and radiological assessment Tables 4.1 and 4.2.329
Figs 4.23A to D: Operative scar and healing of fracture of same patient as in Figures 4.21A to D
Table 4.1   Clinical criteria
Excellent
All of the following: No pain; full range of hip motion; no roentgenographic evidence of progressive changes
Good
No pain; free motion (75% of normal hip motion); no more than slight limp, minimum roentgenographic changes
Fair
Any one or more of the following:
Pain, but not disabling: Limited motion of the hip
No adduction deformity: Moderate limp;
moderately severe roentgenographic change
Poor
Any one or more of the following:
Disabling pain: Marked limitation of motion
or adduction deformity; redislocation:
progressive roentgenographic changes
30
Table 4.2   Roentgenographic criteria
Excellent
All of the following:
Normal relationship between the femoral head and the acetabulum;
Normal articular cartilage space; normal density minimum of the head of the femur; no spur formation; no calcification in the capsule
Good (Minimum changes)
Normal relationship between the femoral head and acetabulum, minimum narrowing of the cartilage space, minimum deossification, spur formation
Fair (Moderate changes)
Normal relationship between the femoral head and the acetabulum. Any one or more of the following:
Moderate narrowing of the cartilage space; mottling of femoral head, areas of sclerosis and decreased density;
Moderated spur formation; moderate to severe capsular calcification; depression of cortex of the femoral head
Poor (Severe changes)
Almost complete obliteration of the cartilage space; relative increase in density of the femoral head, subchondral cyst formation, severe spur formation; acetabular sclerosis
 
Conclusion
To improve the results and final outcome, it is imperative to have emergency reduction of hip. Once the reduction is achieved, further clinical evaluation including CT is indicated to confirm the stability. Repeated attempt of closed reduction should be avoided.
In Pipkin Types I and II, initially try gentle reduction, which is usually successful in Type I whereas open reduction and fixation may be required for Type II fractures, which should be decided after postreduction CT. In Type III surgery is always necessary—fixation of neck fracture with fixation or excision of femoral head fragment. However, if the patient is elderly or if there is severe comminution one may consider total hip joint replacement.2325,27,32,33 In Type IV, usually, surgical treatment is necessary, however, patient can be treated by closed method if dislocation is reducible and stable with small tiny acetabular fragment.
Indomethacin prophylaxis and early postoperative rehabilitation in the form of early nonweight-bearing ambulation with a pair of crutches is necessary. Weight-bearing should be deferred for a period of 10 to 12 weeks, however, regular follow-up and monitoring for the development of osteonecrosis and coxarthrosis3739 should be done.
 
References
  1. Birkett J. Description of a dislocation of the head of the femur complicated with its fracture. Med Circ Trans 1869;52:133.
  1. Pipkin G. Treatment of grade IV fracture-dislocation of the hip. A review. J Bone Joint Surg [Am] 1957;39A:1027-42.31
  1. Thompson VP, Epstein HC. Traumatic dislocation of the hip. A survey of two hundred and four cases covering a period of twenty-one years. J Bone Joint Surg [Am] 1951;33A:746-78.
  1. Epstein HC. Posterior fracture dislocation of the hip. J Bone Joint Surg [Am] 1974;56A:1103-27.
  1. Epstein HC, Wiss DA, and Cozen L. Posterior fracture dislocation of the hip with fractures of the femoral head. Clin Orthop 1985;201:9–17.
  1. Stewart MJ, Milford LW. Fracture-dislocation of the hip. An end-result study. J Bone Joint Surg [Am] 1954;36A:315-42.
  1. Brumback RJ, Kenzora JE, Levitt LE, Burgess AR, Poka A. Fractures of the Femoral Head. Proceedings of the Hip Society, 1986, St. Louis, CV Mosby;  1987.pp.181-206.
  1. Canale ST, Manugian AH. Irreducible traumatic dislocations of the hip. J Bone Joint Surg 1979;61A:7-14.
  1. Bauer GJ, Sarkar MR. Injury classification and surgical approach in hip dislocations and fractures. Orthopade 1997;26(4):304–16.
  1. Chakraborti S, Miller IM. Dislocation of the hip associated with fracture of the femoral head. Injury 1975;7:134–42.
  1. Roeder LF Jr, DeLee JC. Femoral head fractures associated with posterior hip dislocations. Clin Orthop 1980;147:121–30.
  1. Butler JE. Pipkin Type II fractures of the femoral head. J Bone Joint Surg [Am] 1981;63A:1292-6.
  1. Upadhyay SS, Moulton A. The long-term results of traumatic posterior dislocation of the hip. J Bone Joint Surg [Br] 1981;63B:5.
  1. Mowery C, Gershuni DH. Fracture dislocation of the femoral head treated by open reduction and internal fixation. J Trauma 1986;26:1041–4.
  1. Jacob JR, Rao JP, Ciccarelli C. Traumatic dislocation and fracture dislocation of the hip. A long-term follow-up study. Clin Orthop 1987;214:249–63.
  1. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acétabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83(8):1119–24.
  1. Siebenrock KA, Gautier E, Woo AK, Ganz R. Surgical dislocation of the femoral head for joint debridement and accurate reduction of fractures of the acétabulum. J Orthop Trauma 2002;16(8):543–52.
  1. Gardner MJ, Suk M, Pearle A, Buly RL, Helfet DL, Lorich DG. Surgical dislocation of the hip for fractures of the femoral head. J Orthop Trauma 2005;19(5):334–42.
  1. Hougaard K, Thompsen PB. Traumatic posterior fracture-dislocation of the hip with fracture of the femoral head or neck, or both. J Bone Joint Surg [Am] 1988;70A:233-9.
  1. Thorpe M, Swiontkowski MF, Seiler J, Hansen ST. Operative management of femoral head fractures. Orthop Trans 1989;13:51.
  1. Yang RS, Tsuang YH, Hang YS, Liu TK. Traumatic dislocation of the hip. Clin Orthop 1991;265:218–27.
  1. Swiontkowski MF, Thorpe M, Seiler JG, Hansen ST. Operative management of displaced femoral head fractures: Case-matched comparison of anterior versus posterior approaches for Pipkin I and Pipkin II fractures. J Orthop Trauma 1992;6:437–42.32
  1. Marchetti, Michael E, Steinberg, Gerald G; Coumas, James M; Intermediate-Term Experience Of Pipkin Fracture-Dislocations of the Hip [Original Article]. Journal of Orthopedic Trauma 1996;10(7):455–61.
  1. Kloen P, Sienbenrock KA, Raymakers ELFB, Marti RK, Ganz R. Femoral head fractures revisited. Eur J Trauma 2002;28:221–33.
  1. Matejka J, Pavelka T. Fractures of the femoral head. Acta Chir Orthop traumatol Cech 2002;69(4):219–2.
  1. Trueta J, Harrison MHM. The normal vascular anatomy of the femoral head in adult men. J Bone Joint Surg Br 1953;35B:442-61.
  1. Hougaard K, Thomsen PB. Coxarthrosis following traumatic posterior dislocation of the hip. J Bone Joint Surg 1987;69A:679-83.
  1. Bosse MJ, Poka A, Reinert CM, Ellwanger F, Slawson R, McDevitt ER. Heterotopic ossification as a complication of acetabular fracture. J Bone Joint Surg [Am] 1988;70A:1231-7.
  1. Brooker AF, Owerman JW, Robinson RA, Riley LH. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg [Am] 1973;55A:1629-32.
  1. Healy WL, Lo TCM, DeSimone AA, Rask B, Pfeifer BA. Single dose irradiation for the prevention of heterotopic ossification after total hip arthroplasty. J Bone Joint Surg [Am] 1995;77:590–5.
  1. Moed B, Maxey J. The effect of indomethacin on heterotopic ossification following acetabular fracture surgery. Orthopedic Transactions 1989;13:759.
  1. Durabkasa O, Kan N, Canbora K, Gorgec M. Factors affecting the results of treatment in traumatic dislocation of the hip. Acta Othop Traumatol Turc 2005;39(52):133–41.
  1. Kelly PJ, Lipscomb PR. Primary vitallium-mold arthroplasty for posterior dislocation of the hip with fracture of the femoral head. J Bone Joint Surg [Am] 1958;40A:675-80.
  1. Gautier E, Ganz K, Krtigel N, Gill T, Ganz R. Anatomy of medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br 2000;82B:679-83.
  1. Ordway B, Xeller CF. Transverse computerized axial tomography of patients with posterior dislocation of the hip. J Trauma 1984;24:76–9.
  1. Kidwai AS, Patel A, Wilson C, Gladden P, Griffith HJ. Radiologic case study. Pipkin type II fracture of the right femoral head: Orthopedics 2004;27(9):880,1005-8.
  1. Schiedel F, Rieger H, Joosten U, Meffert R. Not “only” a dislocation of the hip: Functional late outcome femoral head fractures; Unfallchirurg 2006;109(7):538–44.
  1. Jessberger S, Blattert TR, Wagner R, Weckbach A. Reducing approach-associated morbidity in fracture dislocation of the femoral head—A longitudinal study (1982-2000); Zentralbl Chir 2002;127(6):485–9.
  1. Stannard JP, Harris HW, Volgas DA, Alonso JE. Functional outcome of patients with femoral head fractures associated with hip dislocations, Clinical Orthops; 2000.pp.44-56.

Fracture Neck Femur in Childrenchapter 5

Fracture neck femur in children is rare as compared to the adults and accounts for less than 1 percent of all pediatric fractures.13 Incidence of fracture neck femur in children is less than 1 percent of adult fracture neck femur.1 Though this injury is infrequently seen in children, the complication rate of this fracture is very high and devastating. The fracture neck femur in adults differs from that in children because of the presence of the physis and vascularity of the vessels that supply the femoral head. Severe trauma is required to produce this fracture in the child and the overall rate of complication has been reported as ranging from 20 to 92 percent. The vulnerability of vascular supply to the proximal femoral epiphysis and complication of avascular necrosis is frequently observed. The injury can also damage the proximal femoral physis resulting in coxa vara deformity with further growth retardation regardless of excellence of reduction. Conversely, if the greater trochanteric apophysis is permanently closed, coxa valga deformity may develop in future. Femoral neck fractures in children also differ from those in adults in that a child can tolerate immobilization much more readily than an adult. Thus, more options for treatment are available including traction, hip spica and bed rest in addition to operative treatment. Both the treatment guidelines and the frequency and the type of complications are dependent on the type of fracture. The classification described by Delbet4 (1928) and popularized by Colonna5 (1928) is generally used for this injury. By and large, fracture neck femur in children is a rare injury and one comes across very few cases in the lifetime of a general orthopedic surgeon.
 
Anatomy
At birth there is only a single proximal femoral physis. The medial portion of it becomes the subcapital physis whereas the lateral portion becomes the greater trochanteric physis. A normal femoral neck angle is present at the age of one year. The growth and configuration of the proximal femur are influenced at this age by the interaction of these two separate centers of ossification. The proximal femoral epiphysis ossifies at about four years of age. The blood supply of the femoral head was observed originally by 34J Trueta6 (1957) and later refined and augmented by Chung7 (1976) and Ogden8 (1974) (Figs 5.1A to C).
Figs 5.1A to C: The arterial blood supply of femoral head in children
  1. The vessels of Ligamentum teres are of virtually no importance. They contribute very little to the blood supply to the femoral head until age eight, and then only about 20 percent in an adult.
  2. At birth, the branches of the medial and lateral circumflex arteries (metaphyseal vessels) traversing the femoral neck predominantly supply the femoral head. These arteries gradually diminish in size as the cartilaginous physis develops and forms a barrier that prevents the penetration of these vessels in the femoral head. This metaphyseal blood supply is virtually nonexistent by age four.
  3. When the metaphyseal vessels diminish, the lateral epiphyseal vessels predominate, and the femoral head is primarily supplied by these vessels, which bypass the physeal barrier.
  4. Ogden noted that the lateral epiphyseal vessels are actually two branches rather than one, the posterosuperior and posteroinferior branches from the medial circumflex artery. At the level of the intertrochanteric groove, the medial circumflex artery branches into a retinacular arterial system (the posterosuperior and posteroinferior arteries), and these two arteries immediately penetrate the capsule and traverse proximally (covered by retinacular folds) along the neck of the femur to supply the femoral head peripherally and proximally to the physis.35
  5. Therefore, capsulotomy per se does not damage the blood supply to the femoral head unless it violates the intertrochanteric notch or damages the lateral ascending cervical vessels along the neck of the femur.
  6. At about the age of three to four years the lateral posterosuperior vessel predominates and supplies all the anterior lateral portion of the epiphysis.
  7. The posterosuperior and the posteroinferior arteries persist throughout life and supply the femoral head.
  8. Ogden8 maintains that as the multiple (immature) blood supply changes with age to a limited (mature) blood supply, vascular compromise to the epiphysis can occur, that is occlusion of the posterosuperior branch of the medial circumflex artery can cause avascular necrosis to the anterior lateral portion of the femoral head.
 
Clinical Features
Almost all the hip fractures in children are caused by severe, high-energy trauma unlike osteoporotic neck fractures in the elderly.
Clinically, the diagnosis of fracture neck femur is diagnosed by pain in the hip, shortening, and external rotation of extremity and pain on attempted movements. Plain radiography AP and lateral views confirm the injury on most of the occasions. Rarely, computed tomography (CT) scan, ultrasonography or magnetic resonance imaging (MRI) may be necessary in infants or toddlers. Magnetic resonance imaging (MRI) is recommended as the primary study for children whose history and physical examination are highly suggestive of fracture neck femur.
 
Classifications
Delbet's classification4 (four-part classification 1928) is most commonly used (Figs 5.2A to D).
Figs 5.2A to D: Delbet's classification of fracture neck femur in children
36
  1. Transepiphyseal fractures (with and without dislocation of the femoral head from the acetabulum)
  2. Transcervical fractures (displaced and nondisplaced)
  3. Cervicotrochanteric fractures (displaced and nondisplaced)
  4. Intertrochanteric fractures.
 
Delbet's Classification of Fracture Neck Femur in Children
 
Type I: Transepiphyseal Fractures
These are the least common fractures (about 8–10%) occurring through the proximal femoral epiphysis.13 Approximately 50 percent of these transepiphyseal separations had dislocation of the femoral head from the acetabulum, which has a very poor prognosis. Severe violence is necessary to produce this injury and in infants it may be a result of child abuse. However, in adolescents less trauma may be necessary since it is part of the spectrum of slipped capital femoral epiphysis (Figs 5.3A to H).
In infants and children who are victims of child abuse, it might be difficult to diagnose transepiphyseal separation but the injury must be strongly suspected in infants with apparently shortened extremity which is held in flexion, abduction, and external rotation.
Figs 5.3A to H: Type I transepiphyseal fracture neck femur in a 16-year-old obese boy treated by closed screw fixation. (A and B) Preoperative; (C and D) Six months postoperative; (E to H) Eleven years postoperative
37
In addition to plain radiography, ultrasonography, arthrography and MRI may be needed to diagnose the injury. In older children and adolescents the diagnosis is more readily apparent on physical examination and plain radiography, especially when there is history of severe trauma.
 
Treatment
If the patient has no dislocation of physis, epiphyseal separation can be treated by percutaneous smooth pin fixation by closed procedure. If the fracture is displaced but not dislocated, gentle closed reduction and fixation by smooth pins is the appropriate treatment for this Type I lesion. However, in this type of slipped capital femoral epiphysis in adolescents, fixation in situ by 2 to 3 cancellous screws may be performed, where early fusion of epiphysis is desirable. Ratliff (1968) and Rang (1972) recommended gentle closed reduction followed by hip spica, however, Lam noted that displacement could occur after this form of conservative treatment also and suggested fixation. Patient can have the complication of avascular necrosis and nonunion in this group.
Transepiphyseal separations with dislocation of the femoral head always require open reduction and have a very poor prognosis. If the femoral head is dislocated, multiple attempts of closed reduction are avoided because of fear of jeopardizing the already tenacious blood supply. CT scan is more important and helpful to verify the location of the dislocated femoral head, which will facilitate surgical approach (anterior or posterior).
 
Type II: Transcervical Fractures
This type of fracture has the largest group amongst all types of fracture neck femur in children. This accounts for the greatest percentage, almost 50 percent of fracture neck femur in children, as compared to about 40 percent in other published series.13 Most of these fractures are displaced and the amount of displacement is directly related to the frequency of the development of osteonecrosis. Fracture displacement appears to be responsible for the vascular damage because the maximum amount of displacement probably occurs initially at the time of injury. According to Weber9 (1978) et al. Boitzy10 (1980), Hoekstra11 (1983) and Lichtendhal12 (1983), the capsular distention by the fracture hematoma and subsequent tamponade of vessel is related to increased incidence of avascular necrosis, and the evacuation of this hematoma may decrease the incidence of osteonecrosis. Pforringer and Rosemeyer13 (1980) reported fewer occurrences of osteonecrosis, premature closure of physis and nonunion following immediate operative treatment than after delayed operative or nonoperative treatment regardless of the type of fracture. They recommended decompression of the capsule by 38fenestration or aspiration for un-displaced fractures treated conservatively. Swiontkowski and Winquist3 (1986) recommended immediate open reduction and internal fixation with anterior capsulotomy for the evacuation of the fracture hematoma for all displaced Type II and Type III fractures. All fractures should be fixed either by smooth pins (Knowles pins, Austin Moore pins) or thick K-wires (Figs 5.4 to 5.10).
At times the physis may be penetrated to enhance the stability even at the cost of epiphyseal damage. Rarely, open reduction of the fracture may be done to achieve proper reduction.
Figs 5.4A to D: Type I transepiphyseal fracture neck femur in a 14-year-old obese boy treated by closed screw fixation
Figs 5.5A and B: X-ray showing Type II transcervical fracture neck femur fixed by two Austin Moore pins
39
Figs 5.6A to D: X-ray showing Type II transcervical fracture neck femur fixed by multiple pins
Figs 5.7A to E: X-ray showing Type II transcervical fracture neck femur fixed by three Austin Moore pins
40
Figs 5.8A to D: X-ray showing Type II transcervical fracture neck femur fixed by three Austin Moore pins
Figs 5.9A to D: X-ray showing Type II transcervical fracture neck femur fixed by three Austin Moore pins
Figs 5.10A to D: X-ray showing Type II transcervical fracture neck femur in a child of osteopetrosis fixed by three Austin Moore pins
Garber, et al.14 (1985) concluded that occurrence of avascular necrosis was related to the degree of initial fracture 41displacement and also to the location of the fracture and that immediate open reduction and internal fixation did not prevent avascular necrosis after displaced Types II and III fractures. Different authors reported a 30 to 43 percent incidence of osteonecrosis in these types of fractures because of different rates of avascular necrosis; hence differentiation should be made between displaced and undisplaced fracture neck femur in children as that is what influences the rate of avascular necrosis rather than the type of treatment. In these groups of patients if the fracture is displaced, chances of developing avascular necrosis within six months are very high and all these children may be treated conservatively for osteonecrosis.
 
Complications
  1. Loss of reduction
  2. Osteonecrosis
  3. Resultant coxa vara
  4. Premature physeal closure
  5. Nonunion.
All these above complications may be influenced by the type of treatment. According to Lam15 treating all undisplaced or minimally displaced fractures (except severely displaced fracture neck femur) reported a significantly decreased avascular necrosis rate but increased incidence of coxa vara and nonunion. Coxa vara deformity is not always iatrogenic and is mainly caused by over-reduction or lack of reduction. It can occur secondary to osteonecrosis and subsequently premature closure of the proximal femoral physis.
 
Treatment
Internal fixation is the treatment of choice for transcervical fracture neck femur in children. Irrespective of the displacement, closed reduction followed by internal fixation with smooth, threaded pins or cannulated hip screws.13,1622 If possible threads of the screw or pins should not penetrate the physis, however, fixation of the fracture is more important than penetration of the physis.
 
Type III: Cervicotrochanteric Fractures
This group is the second largest amongst fracture neck femur in children and accounts for the second most common type of proximal femoral fractures (about 25–30%) because of the relative weakness of the fernoral neck at the junction with the greater trochanter13 and is analogous to the basi-cervical fracture seen in the adults (Figs 5.11 to 5.13).
Most of these fractures are displaced, however if undisplaced, the fracture can be treated with hip spica in abduction, preceded by 3 to 6 weeks 42traction.
Figs 5.11A to H: X-ray showing Type III cervicotrochanteric fracture neck femur fixed by Austin Moore pins and one 4 mm cancellous screw showing good healing at 2 months and 6 months after surgery
Figs 5.12A to D: X-ray showing Type III cervicotrochanteric fracture neck femur fixed by multiple Austin Moore pins
43
Figs 5.13A to E: X-ray showing Type III cervicotrochanteric fracture neck femur fixed by Austin Moore pins showing good healing at 6 months
When the fracture is displaced closed reduction and internal fixation avoiding the physis if possible in younger children is done as this may cause avascular necrosis. When treated conservatively fracture can get displaced subsequently resulting in coxa vara and malunion. However, if displacement occurs, immediate reduction and internal fixation is indicated.
In this group the incidence of avascular necrosis is less and the patient can be treated by nonweight-bearing, rest and exercises. Usually, nonunion is not noticed in this group.
 
Treatment
Though undisplaced cervicotrochanteric fractures, especially in children can be treated adequately in abduction hip spica, commonly this fracture is operated and fixed by cancellous screws. Undisplaced fractures can be treated conservatively in hip spica, but if there is any doubt regarding the displacement then fracture should be treated as a displaced one and child should be treated with internal fixation to avoid coxa vara.
 
Type IV: Intertrochanteric Fracture
Intertrochanteric fracture femur in children (Figs 5.14 to 5.16) is far less common than the transcervical and cervicotrochanteric fractures and 44accounts for 11 to 17 percent.13
Figs 5.14A to H: X-ray showing Type IV intertrochanteric fracture neck femur fixed by multiple cancellous screws showing good healing at 6 months
The fracture may be comminuted but because of the osteogenic potential of the children, nonunion almost never occurs. This fracture can be treated conservatively, but these patients are usually operated mainly to prevent coxa vara. An acceptable position can usually be obtained in young children by skin or skeletal traction followed by limb in abduction hip spica. Occasionally, if the fracture cannot be reduced, gentle closed manipulation can be done and fracture stabilized by smaller sized implants, like SP nail plate or DHS, cancellous screws.
Sometimes open reduction and internal fixation may be necessary because of malreduction/inability to obtain acceptable closed reduction.45
Figs 5.15A to D: X-ray showing Type IV intertrochanteric fracture neck femur fixed by multiple Austin Moore pins showing good healing at 4 months
Figs 5.16A and B: X-ray showing Type IV intertrochanteric fracture neck femur, fracture was treated conservatively by traction and hip spica
 
Nonunion Group
The complication of nonunion is infrequently seen in children. This complication is seen if the fracture is fixed in distraction. It is also commonly seen if the fracture neck femur, especially, transcervical, and cervicotrochanteric fracture if treated conservatively. In such situations the subtrochanteric abduction osteotomy should be done along with osteosynthesis and bone grafting is usually not necessary.46
 
Discussion
Undisplaced fracture neck femur in children, cervicotrochanteric fractures and fractures Pauwel's I and II (angle less than 50°) are considered stable fractures and reduction can be maintained by Whitman method (Figs 5.17A to C).
If the angle is greater than 50° it is considered unstable and surgical fixation is necessary (may be coupled with primary subtrochanteric abduction osteotomy). Earlier, manipulative reduction and immobilization in plaster spica was employed as a routine and was a common method of treatment if the fracture was undisplaced or if minimally displaced preceded by skin/skeletal traction for 3 to 4 weeks, but presently osteosynthesis by closed reduction (rarely open reduction) and stabilization by Knowles pins/Austin Moore pins is a preferred method of treatment. This should be followed by hip spica for better compliance.
Lam15 (1971), in his study of 75 fracture neck femur reached the following conclusions:
  1. Undisplaced transcervical and cervicotrochanteric fractures can be adequately treated by simple immobilization in a plaster of Paris cast.
  2. All pertrochanteric fractures can be satisfactorily treated by conservative means.
  3. Minimally displaced transcervical and cervicotrochanteric fractures with considerable bony contact are best treated by closed reduction and immobilization in a plaster of Paris cast.
  4. Displaced transcervical and cervicotrochanteric fractures with loss of all bony contact present a difficult problem. Closed reduction should be attempted, if successful, hip is immobilized in one and one-half hip spica or well leg traction in younger children or by insertion of two or more threaded pins reinforced by plaster spica in older children. If closed reduction fails open reduction is to be performed.
Ingram and Bachynski20 (1953) recommended routine use of internal fixation preceded by closed reduction in all fracture neck femur in children, except in undisplaced cervicotrochanteric type.
Figs 5.17A to C: Whitman's method of fracture reduction
They cautioned against the 47use of triflanged Smith Petersen nail because of its tendency to distract the fracture and threaded pins or screws to prevent premature physeal closure because of growth arrest by compression of the epiphysis. As and when possible pins should be short of physis, thereby decreasing the chances of growth arrest. They also agreed that use of a cast without internal fixation is not adequate to maintain reduction.
The majority of the patients are treated surgically, since it is felt that no assurance can be given regarding the maintenance of reduction. It was observed that even the initially undisplaced fractures get displaced in spica cast, and hence routinely the fracture neck femur in children are surgically stabilized by implants. Considering all previous series and our experience, by and large fracture neck femur in children should be fixed after gentle manipulation if required and closed pinning under image intensifier by using Austin Moore or threaded pins/4 mm cancellous screws/4 mm cannulated screws and avoiding physeal penetration whenever possible but without affecting the stability.
 
Complications
The displaced fracture neck femur in children still remains an unsolved problem since even with the most perfect anatomical reduction and adequate fixation a normal hip cannot be assured. Following are the common complications observed:
 
Avascular Necrosis
This is the most commonly occurring complication with devastating results as little can be done to salvage the function of the hip joint after development of osteonecrosis. It is usually seen after displaced fractures but can also occur following undisplaced fractures. Development of avascular necrosis is related directly to initial displacement and compromise of blood supply at the time of fracture and the type of treatment (Figs 18A to D. It may be seen as early as six weeks in case of children than in adults even on plain radiographs. Radioisotope scan and MRI may even detect the lesion early.
 
Classification of Avascular Necrosis
According to Ratliff21 (1970) there are three patterns of avascular necrosis fracture neck femur in children (Figs 5.19 and 5.20).
Type I:
Diffuse increased density (sclerosis) accompanied by complete collapse of the femoral head.
Type II:
Increased density localized to a part of the epiphysis with minimal collapse of the femoral head.
Type III:
Increased sclerosis of the neck from the fracture line to the physis, spongy head.
48
Figs 5.18A to D: X-ray showing Type II transcervical fracture neck femur fixed by two cancellous screws, fracture healed in 6 months, but developed avascular necrosis within 2 years
This is helpful to determine the prognosis of the femoral head. Forlin and colleagues reported that 9 out of 14 patients had disabling pain, limitation of range of hip motion and activity with severe femoral head and neck deformity. Children more than 10 years of age had poor results more often than younger ones. In most of the reported series this complication of avascular necrosis is commonly seen in the group of fresh fractures (Figs 5.21A to D) as well as in association with nonunion which develops after surgical treatment. The largest group belongs to the group of transcervical fractures.
Incidence of osteonecrosis in Ratliff's series was 42 percent (in all Type I fractures with dislocations, Type II - 52%, Type III - 27%, Type IV - 14%) (Figs 5.22A to D). Forlin (1992) and associates reported avascular necrosis in 14 out of 16 children with displaced femoral neck fractures, as against Davison and Weinstainthal (1992) figures of 9 out of 19. Clinically, pain and limitation of motion secondary to synovitis may be the only signs of avascular necrosis.
Commonly following conservative methods of treatment are available for the complication of osteonecrosis. Bed rest, nonweight-bearing, crutch walking, along with hip mobilization exercises, motion should be maintained 49during the active period of synovitis.
Figs 5.19A and B: Diagrammatic picture representation of vascularity of femoral head (A) and its damage causing osteonecrosis of femoral head (B)
Figs 5.20A to C: Diagrammatic representation of different types of osteonecrosis of femoral head described by Ratliff AHC
Use of “containment bracing” is considered in children less than 6 years of age. In future some patients may need soft tissue release, osteotomy, arthrodesis and arthroplasty regardless of whether those patients were treated conservatively or not.50
Figs 5.21A to D: X-ray showing Type III cervicotrochanteric fracture neck femur fixed by cancellous screws developed segmental Type II osteonecrosis
Figs 5.22A to D: Diagrammatic representation of different types of osteonecrosis of femoral head, according to the anatomical site of vascular insult
51
 
Coxa Vara
Coxa vara is observed if the children with intertrochanteric fractures are treated conservatively. The patients commonly develop coxa vara secondary to avascular necrosis. The coxa vara is usually related primarily to the type of treatment. Premature closure of the proximal femoral physis with overgrowth of the greater trochanter at an early age may result in varus deformity whereas partial closure may cause either varus or valgus deformity resulting from inferior/superior portion respectively.2224 However, coxa vara may be produced because of loss of initial reduction when treated conservatively in spica cast or because of fixation in varus position at the time of surgery. Sometimes the deformity might be because of avascular necrosis causing collapse of femoral head in varus position. All these patients, including the patients of nonunion, are commonly treated by subtrochanteric abduction osteotomy.
As reported by Lam these deformities remain constant or may even improve slightly with time subsequently causing some shortening and abductor lurch and later on degenerative changes around the hip joint. Corrective subtrochanteric osteotomy with slight valgus adds some length to the extremity and usually provides better results for children older than eight years with coxa vara and those with neck shaft angle of 110° or less.
 
Nonunion
Nonunion is a frequently observed complication in children. Most nonunion needs to be treated by abduction osteotomy and bone grafting may not be necessary (Figs 5.23A to C). Nonunion following fracture neck femur in children has nearly the same incidence as that in adults. It is usually seen that if significant varus position is accepted at the time of treatment without internal fixation, or when the fixation is done with slight distraction or Type III fracture where shearing force is greater attributing to the more vertical fracture line, thus increasing the chances of nonunion.
Figs 5.23A to C: X-ray showing Type III cervicotrochanteric fracture neck femur fixed by cancellous screws developed segmental Type III osteonecrosis
When the 52stability of the fracture is unreliable, fixation should be done into the femoral head, along with the use of the hip spica for immobilization or primary abduction osteotomy should be considered.
A nonunion after fracture neck femur is an indication for necessary operative intervention.22 Similarly, placement of the fracture line more horizontal by converting shearing forces to compression forces by using subtrochanteric valgus osteotomy with and without bone grafting to augment the fracture healing except in pathological fractures in children, followed by spica cast for 3 to 4 weeks is the treatment of choice.
 
Premature Physeal Closure
The exact reason for the premature closure of the physis is not very clear but causes like avascular necrosis, penetration of pins or screws crossing the physis and stimulation of physis after fracture have been implicated. According to Lam,15 Ratliff,21 and Forlin et al.19,25 the incidence was found to be 9 to 20 percent. But Pforringer and Rosemeyer13 found that there was no relation between the above two causes, as the proximal femoral physis contributes little (about 15%) to the entire lower extremity growth while the amount of the shortening is determined by the age at which the physis of extremity closes prematurely.
Patients should be followed for more than 5 to 10 years to detect this complication to label them as premature physeal closure. In hip fractures or proximal femoral fractures a combination of avascular necrosis and premature physeal closure in older children results in minimal limb length discrepancy and such patients should be followed closely by frequent scanogram and wrist X-rays for bone age. It is usually seen that limb length discrepancy following premature closure of the physis is progressive rather than static and this may be treated by the contralateral distal femoral epiphysiodesis.
 
Infection
It is a rare complication after hip fractures. Davison and Weinstein18 (1992) reported only 2 percent septic arthritis out of 19 treated with open reduction, which was also accompanied by avascular necrosis.
 
Summary and Conclusion
Fracture neck femur is an extremely rare injury in children. Transcervical fracture is the most common amongst the group of fracture neck femur in children. Majority of times this fracture needs surgical fixation. Reduction achieved by either closed reduction or open procedure combined with stable fixation to prevent redisplacement is recommended for most of the fractures. Gentle closed manipulation and closed percutaneous fixation of fracture under image intensifier is the ideal treatment for such fractures, 53at times followed by hip spica. As suggested by Flynn et al.27 the fracture should be managed by early operative fixation and immobilization in hip spica. The fracture should be fixed either by threaded pins, smooth Knowles or Austin Moore pins and rarely 4 mm cannulated screw. One should try to avoid physeal penetration by implants, but not at the cost of proper fixation. In comparison with adult hip fractures, these injuries are associated with frequent and serious complications, including avascular necrosis, nonunion, coxa vara and premature physeal closure. Complication of avascular necrosis is seen because of vulnerability to injury of end arterial blood flow and of the osseous anatomy of the child's proximal femur, and at times may be inevitable.26
 
Stress Fracture Neck Femur
Usually, the cause is following repetitive cyclic loading of the hip as seen in elderly patients with osteoporotic bone, military recruits and long distance runners. The diagnosis is difficult, and the differential diagnosis should include:
  • Preslipped capital femoral epiphysis with widening of the physis
  • Synovitis of hip in younger child
  • Secondary to Perthes disease
  • Inflammation
  • Avulsion injuries of the pelvis (anterior superior and anterior inferior iliac spine, ischial tuberosity)
  • Malignant and benign neoplasms (osteoid osteoma, eosinophilic granuloma).
These are evident only after 4 to 6 weeks of the onset of symptoms, on plain radiographs in the form of faint callus formation. There are very few case reports of stress fracture neck femur in children.28
Devas MB29 (1965) suggested two types:
  1. Transverse tension stress fractures–superior portion of the neck is displaced causing severe morbidity. Treatment is by open reduction with cannulated screws before displacement occurs.
  2. Compressive tension stress fractures–inferior portion of the femoral neck causes mild varus deformity in young patients. Treatment is by nonweight-bearing and limitation of physical activity.
A few workers suggested that partial weight-bearing could be allowed at six weeks and full weight-bearing allowed at 12 weeks.
In uncomplicated cases skin traction is given for six weeks and one and half hip spica for six weeks.
In these patients, whenever there is evidence of displacement those fractures should be fixed internally.54
 
References
  1. Ratliff, AH. Fracture neck of the femur in children. J Bone Joint Surg Br 1968;44B:528-42.
  1. Canale ST, Bourland WL. Fractures of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am 1977;59A:431-43.
  1. Swiontkowski MF, Winquist RA. Displaced femoral neck fractures in children and adolescents. J Trauma 1986;26:384–88.
  1. Delbet P. Cited in Colonna PC: Fracture of the neck of the femur in childhood. A report of six cases. Ann Surg 1928;88:902.
  1. Colonna PC. Fracture of the neck of the femur in childhood. A Report of six cases. Ann Surg 1928;88:902.
  1. Trueta J. The normal vascular anatomy of the human femoral head during growth. J Bone Joint Surg Br 1957;39B:358-94.
  1. Chung SM. The arterial supply of the developing proximal end of the human Femur: J Bone Joint Surg Am 1976;58A:961-70.
  1. Ogden JA. Changing patterns of proximal femoral vascularity. J Bone Joint Surg Am 1974;56A:941-50.
  1. Weber BG, Brunner C, Freuler F. Treatment of fractures in children and adolescents. New York. Springer-Verlag,  1978 (English translation, 1980).
  1. Boitzy A. Fractures of the proximal femur. In Weber BG, Brunner C, and Grueler F (Eds): Treatment of fractures in children and adolescents. Berlin, Springer-Verlag,  1980.
  1. Hoekstra HJ, Lichtendbal D. Pertrochantric fracture in children and adolescents. J Pediatr Orthop 1983;3:587–91.
  1. Lichtendhal D. Pertrochanteric fractures in children and adolescents. J Pediatr Orthop 1983;3:587–91.
  1. Pforringer W, Rosemeyer B. Fractures of the hip in children and adolescents. Acta Orthop Scand 1980;51:91–108.
  1. Gerber C, Lehmann A, Ganz R. Femoral neck fractures in children: experience in 7 Swiss AO hospitals. Orthop Trans 1985;9:474.
  1. Lam SF. Fractures of the neck of the femur in children. J Bone Joint Surg Am 1971;53A:1165-79.
  1. Canale ST. Fractures of the hip in children and adolescents. Orthop Clin North Am 1990;21:341–52.
  1. Canale ST, Tolo VT. Fractures of femur in children. Inst Course Lecture J Bone Joint Surg Am 1995;77A:294-315.
  1. Davison BL, Weinstein SL. Hip fractures in Children: A long term follow-up study J Pediatr Orthop 1992;12:355–58.
  1. Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop 1992;12:164–8.
  1. Ingram AJ, Bachynski B. Fractures of the hip in children, treatment and results. J Bone Joint Surg Am 1953;35A:867-87.
  1. Leung PC, Lam SF. Long-term follow-up of children with femoral neck fractures. J Bone Joint Surg Br 1986;68B:537-40.
  1. Ratliff AHC. Traumatic separation of the upper femoral epiphysis in children. J Bone Joint Surg Br 1968;50B:757-70.55
  1. Ratliff AHC. Complications after the fractures of the femoral neck in children and their treatment. Bone Joint Surg Br 1970;52B:175.
  1. Swiontkowski MF. Complications of the hip fractures in children. Clin Orthop 1989;4:58–62.
  1. Forlin E, Guille JT, Kumar SJ, Rhee KJ. Complications associated with fractures of the neck of the femur in children. J Pediatr Orthop 1992;12:503–09.
  1. Kay SP, Hall JE. Fracture of the femoral neck in children and its complications. Clin Orthop 1993;294:193–5.
  1. Flynn JM, Wong KL, Yeh GL, Meyer JS, Davidson RS. Displaced fractures of the hip in children: Management by early operation and immobilization in hip spica cast. Bone Joint Surg Br 2002;84B:108-12.
  1. Roman M, Reco R, Moreno JC, Fuentes S, Collantes F. Stress fracture of the femoral neck in a child, case report and review of the literature. Acta Orthopaedic Belgica; 2001.pp.67-3.
  1. Devas MB. Stress fracture of the femoral neck. J Bone Joint Surg 1965;47B:728-38.

Fracture Neck Femur in Adultschapter 6

The femoral neck fractures are intracapsular, located in the area bounded by the femoral head superiorly and by the greater and lesser trochanter inferiorly. Lately, the incidence of hip fractures is increasing fast among younger individuals due to high-energy trauma following vehicular accidents. The average age of the patients who sustain fracture neck femur is about three years younger than those with trochanteric fracture. Fracture neck femur should be considered fractures through weak and porotic bone and there is a strong association between osteomalacia, osteoporosis and fracture neck femur. Aitken1 in 1984 demonstrated that 84 percent of patients with fracture neck femur had either mild or severe osteoporosis, and fracture occurs due to low-energy trivial trauma. The mechanism of injury is secondary to fall producing direct blow over the greater trochanter, or external rotation of the extremity occurring during the fall. Head of the femur is firmly fixed by anterior capsule and iliofemoral ligaments, during fall the neck rotates posteriorly creating fracture of the neck of the femur. The posterior cortex impinges on the acetabulum, and the femoral neck buckles. Whether the fall is first or the fracture is first is still unresolved. The third mechanism is cyclical loading, which produces microfractures and macrofractures.
 
Presentation and Diagnosis
Patients with displaced intracapsular fractures usually complain of pain in the entire hip region and groin. The lower limb is kept in external rotation, abduction and slight shortening. These patients may not have extreme external rotation deformity which is commonly noticed after hip dislocation or intertrochanteric fractures, because of partially intact capsule which will resist full external rotation deformity. One should avoid every effort to perform hip joint motion. The patients with displaced fracture just cannot stand and attempted movements of hip are painful and restricted. Patients with impacted or undisplaced fractures may be ambulatory with minimal pain. A few patients experience little pain after trivial trauma, but continue to walk. They have no major problem and hence continue their daily activities. Unfortunately, if they receive another minor twisting episode, then previously impacted fracture gets completed and full and frank picture of fracture is 57observed. It is necessary to diagnose at this first stage. If impacted fracture can be seen on good quality internal rotation view of hip, immediate fixation with three screws has a very good end result. Unfortunately, when the fracture is fully displaced, then the rate of complications of osteonecrosis and nonunion increases even after good fixation. It is important to obtain careful medical history of comorbidities, and detailed history of pre-injury status of the patient since it can affect both the treatment and prognosis. In displaced fractures, usually, one sees the classical presentation of externally rotated limb with shortening. There is marked tenderness around the hip and greater trochanter. Attempted movements of hip are very painful. The diagnosis is easily confirmed by routine X-rays, which reveal fracture type, degree of posterior comminution, amount of porosis, to decide the line of surgical treatment.
Patient should be subjected to standard X-ray examination, which includes X-ray pelvis AP including both hips. AP pelvis X-ray allows comparison of involved side with the contralateral side, which can diagnose undisplaced and impacted fractures. The lateral X-ray is necessary to look for posterior comminution in the femoral neck and proximal femur but lateral X-ray is very painful to take and hence it is generally done during surgery under anesthesia. Anteroposterior X-ray of the hip must be done in internal rotation to see the whole neck. This is easily done by tying the great toes of both feet together at the time of taking X-ray (Fig. 6.1), otherwise the fracture is likely to be missed.
When a hip fracture is suspected but not apparent on standard radiographs, magnetic resonance imaging (MRI) provides an early diagnosis of occult fractures around the hip (Figs 6.2 and 6.3) and may decrease the hospital stay by expediting the definitive treatment (Rizzo PF et al. 19932).
Fig. 6.1: Clinical picture while taking X-ray for fracture neck femur with great toes tied together for internal rotation of hip for proper assessment of entire neck
58
Fig. 6.2: MR scan showing occult fracture neck femur
Figs 6.3A to H: Plain X-rays not showing any obvious fracture on day 1; however it was obvious on MRI performed after 15 days. Fracture got displaced and had to be treated by bipolar hemiarthroplasty
59
 
Classification
There are four common classifications of femoral neck fractures amongst several different systems. These classifications are based on anatomical location of fracture neck femur, direction of the fracture angle, and displacement of fracture fragments.
 
Anatomic Location
Intracapsular fracture neck femur is classified into subcapital, transcervical and basicervical depending upon its anatomical location. The majority of fractures are subcapital and transcervical. Since subcapital and transcervical regions are intracapsular it exhibits different characteristic than basicervical, which is extracapsular. Though the exact location of the fracture in the femoral neck cannot be determined precisely by radiography, subcapital fracture and transcervical fracture have a very high incidence of osteonecrosis and nonunion (Fig. 6.4).
 
Fracture Angle (Pauwels’ Classification)3
The classification system proposed by Pauwels in 1935 is based on the angle of inclination of the fracture line and is divided into three types:
Type I:
Fracture line 30° from the horizontal
Type II:
Fracture line 50° from the horizontal
Type III:
Fracture line 70° from the horizontal
Pauwels’ classification is based on the X-ray shadow of the fracture line. The more the vertical the fracture line, greater the risk of nonunion because of increased shear stresses across the fracture. As the fracture progresses from Type I to Type III, the obliquity of the fracture line increases and the shear forces at the fracture site also increase, increasing the chances of nonunion (Figs 6.5A to C).
Fig. 6.4: Classification according to anatomical location
60
Figs 6.5A to C: Pauwels’ classification
It is stated that the inclination of the fracture line is more a reflection of radiographic technique than true anatomy, which varies in obliquity with rotation of distal fragment. Garden believed that any change in the obliquity of the fracture line was the result of mis-interpretation of the X-rays and therefore, it is said to be a better measure of reduction than an indication of the angle at fracture site. As a result and because of lot of controversy this classification is infrequently used nowadays.
 
Fracture Displacement (Garden's Classification)4
The most popular classification of fracture neck femur, introduced by Garden in 1961, is based on the degree of fracture displacement noted on prereduction AP X-ray (Figs 6.6A to D).
Type I: Incomplete or impacted fracture in which the bony trabeculae of the inferior portion of the femoral neck remain intact. This group includes the “abducted impaction (valgus impacted) fracture”.
Type II: Complete fracture without displacement of the fracture fragments. The X-ray shows weight-bearing trabeculae interrupted by a fracture line across the entire neck of the femur.
Figs 6.6A to D: Garden's classification
61
Type III: Complete fracture with partial displacement of the fracture fragments. The bony trabeculae of the femoral head do not line up with the trabeculae of the acetabulum indicating that the femoral head is rotated as a result of incomplete displacement between the fracture fragments. The retinaculum of the hip remains attached to, and maintains the continuity between the proximal and distal fragments.
Type IV: Complete fracture with total displacement of the fracture fragments, where all continuity between proximal and distal fragments is disrupted, the femoral head assumes its normal relationship in the acetabulum and trabecular pattern of the femoral head lines up with the trabecular pattern of the acetabulum.
 
Orthopedic Trauma Association (OTA) Classification
Alphanumeric or compressive classification of fracture neck femur suggested by AO/OTA ranges from 31B1 to 31B3, in which 31 is for proximal femur group and B is for fracture neck femur subgroup. B1 is subcapital fracture with slight displacement, B2 fractures are transcervical, and B3 are displaced subcapital fractures. Subgroups further specify fracture geometry (Figs 6.7A to C).
This classification is mainly used for proper documentation and research purposes.
The simplest and best classification is to classify the fracture into either nondisplaced fracture neck femur (Garden Types I and II) or displaced fractures Garden Types III and IV).
 
Fracture Neck Femur and Vascularity
Major complication after fracture neck femur is osteonecrosis of femoral head, which occurs in 9 to 35 percent512 of displaced fracture neck femur. The degree of fracture displacement determines the severity of vascular damage, the major supply being from the lateral epiphyseal artery system.1315 The femoral head has vascular supply from three sources:
  1. Intraosseous cervical vessels that cross the marrow spaces from below
  2. The artery of ligamentum teres—medial epiphyseal vessels
  3. Retinacular vessels, branches from extracapsular arterial ring—lateral epiphyseal vessel which runs along the femoral neck.
When fracture neck femur occurs the intraosseous cervical vessels are disrupted and femoral head nutrition depends on the remaining retinacular vessels and artery along the ligamentum teres. Although the adverse effect of femoral neck fractures on the vascularity of femoral head flow (Fig. 6.8) has been documented, perfect anatomical reduction of femoral neck fractures has been shown to reduce the risk of osteonecrosis of femoral head. Stable fracture fixation allows revascularization to proceed in an optimal mechanical environment and reduces the risk of further vascular damage.16,1762
Figs 6.7A to C: AO/OTA classification
Fig. 6.8: Vascularity around the neck of femur
63
The role of early aspiration or surgical decompression of the hemarthrosis in the management of fracture neck femur remains controversial. There are studies which show that increased intracapsular pressure from hemarthrosis compromises femoral head vascularity and may lead to osteonecrosis in both displaced and undisplaced fractures.1827 If this hematoma is aspirated early, its effect, like cardiac tamponade is avoided. Many authors disagree on this issue, but a few practice early aspirations.
 
Evolution of Surgical Treatment
Smith Petersen in 193128 reported the use of triflanged nail for stabilization of fracture neck femur (Fig. 6.8), which initially was done as open method, but soon it changed to closed reduction and stabilization by triflanged nail. This nail was modified by Johansson29 and Wescott30 and was made cannulated for easy insertion on guidewire. Several major problems were associated with the use of Smith Petersen nail, including the inability to maintain fracture reduction, implant backout, and joint penetration of implant through the femoral head. Thornton31 added a side plate to secure more firm fixation and Jewett designed a one-piece nail by adding side plate to triflanged nail. However, this one-piece nail did not permit fracture impaction, and resulted in high incidence of hip joint penetration. Subsequently, Charnley32 designed new implant where concepts of controlled collapse impaction were combined by using compression screw in a sleeve plate device. Sliding nail plate devices were subsequently developed that controlled fracture impaction and prevented rotation. Pugh,33 and Massie10 developed such implants with 135 and 150° side plate with a triflanged telescoping nail. Finally, sliding hip screw was evolved and had advantages over the nail plate, because of use of large diameter lag screw, which provides better fixation in osteoporotic bone and allows controlled collapse. Rotation of femoral head is avoided by using additional screw which is inserted first just superior to the proposed centrally placed lag screw.
 
Treatment
All patients who sustain hip fracture are admitted to the hospital and maintained on bed rest. Earlier we used to put Buck's traction with 5 lb weight to prevent further displacement and additional soft tissue injury. But currently it is preferred to keep the limb in the position of comfort, usually slight hip flexion, and external rotation and the limb supported by pillow under the knee.34 The surgery should be performed as soon as possible after medical fitness of all comorbid conditions, especially cardiorespiratory function and correction of fluid and electrolyte imbalance. The operative management consists of fracture reduction and stabilization followed by early mobilization. This has become the standard regimen, which also reduces a lot of complications of prolonged bed rest. The surgery should be decided 64on the basis of whether the fracture is impacted and undisplaced or displaced fracture neck femur (Fig. 6.9).
 
Impacted and Undisplaced Fracture Neck Femur (Figs 6.10A to F)
There should be distinction between impacted fracture and undisplaced fracture neck femur. In impacted fracture both fracture fragments are jammed in each other in valgus impacted position.
Fig. 6.9: X-ray showing impacted fracture neck femur
Figs 6.10A to F: X-ray showing undisplaced fracture neck femur (Fig. 6.9), got displaced in 6 weeks when conserved and had to be fixed by three cancellous screws
65
A patient with this fracture can walk with minimal discomfort, and such impacted fracture if left alone will remain impacted most of the time.
Whereas undisplaced fracture is one where fracture fragments have remained in good position at the time of taking X-ray and are likely to get displaced later. They need immediate fixation. Mental segregation of impacted and undisplaced fracture is very important since there is a likelihood of committing an error. Undisplaced or nondisplaced fractures that are not impacted do not have inherent stability like impacted fractures and are at higher risk of fracture displacement. So as a rule of thumb fix all fractures even if they are impacted.
  1. All patients with valgus impacted fracture or undisplaced fracture neck femur should be stabilized with internal fixation by using three parallel cancellous screws as early as possible, preferably within 24 hours. Three 6.5 cancellous screws (short thread 16 mm), should be placed in a triangular position in an inverted triangle configuration.
  2. One may consider stabilization by sliding hip screw with superiorly placed derotation screw, which is a biomechanically stronger implant as compared to multiple screws, and minimizes the risk of subsequent subtrochanteric stress fracture. It has the disadvantage of larger surgical exposure.
 
Displaced Femoral Neck Fractures
There are a number of options for the surgical management of femoral neck fractures including multiple cancellous screws, sliding hip screw, replacement hemiarthroplasty, bipolar replacement and total hip joint replacement.
 
Closed or Open Reduction and Internal Fixation
Fixation options include multiple cancellous lag screws, and a sliding hip screw after obtaining the anatomical acceptable reduction.3545 After closed reduction, high-quality radiographs are essential to evaluate the acceptability and quality of reduction. Lowell35,36 demonstrated experimentally that all X-ray images of an anatomic femoral head neck junction should reveal the convex outline of the femoral head meeting the concave outline of the femoral neck, regardless of the X-ray projection (Figs 6.11A and B).
This outline produces the image of an S curve. Malreduced fracture does not produce that S curve. A varus reduction is known to result in an increased incidence of nonunion of fracture neck femur, whereas with valgus reduction, the chances of healing are excellent with the occasional incidence of osteonecrosis. Because of problems of fracture malreduction, most authors favor near-anatomical reduction of neck fractures as far as possible. Garden14,15 investigated the effects of the quality of reduction on both early and late results after femoral neck fractures and concluded that 66acceptable reduction decreases the incidence of nonunion, osteonecrosis and degenerative arthritis.
Figs 6.11A and B: Lowell's lines that the cortices of an anatomically aligned femoral head and neck will project shallow S- or reverse S-shaped curves on both X-ray views. Malalignment is demonstrated by a flattening of one curve and a sharp apex on the opposite side seen in Figure 6.11B
Fig. 6.12: Garden's alignment index to standardize acceptable fracture reduction
He developed an alignment index to standardize the acceptable fracture reduction. The alignment index is measured on the AP and lateral radiographs taken after reduction (Fig. 6.12). In AP view the angle formed by the central axis of the medial trabecular system in the femoral head and the medial cortex of the femoral shaft is measured, which normally measures about 160°. Whereas in lateral view the central axis of the femoral head and neck normally lie in a straight line measuring about 180°. Garden4648 concluded that the alignment index after reduction should be within the range of 155 to 180° in both AP and lateral views. Alignment index of an angle of 180° on lateral views and 140 in AP view + or – 5 is considered acceptable.
Similarly, stability of reduction is equally important and its evaluation, especially on lateral views is essential before fixation of fracture. It is 67necessary to identify the posterior comminution at the fracture site. Posterior comminution leads to loss of buttressing effect posteriorly, with subsequent risk of loss of reduction and high incidence of nonunion.
If the fracture is not reduced after one to two attempts of gentle closed reduction, open reduction is necessary. Usually, the open reduction is done through an anterolateral approach. The patient is kept supine on a radiolucent table, avoiding the traction to facilitate the manipulation and disengagement of the fracture fragments. Usually, a Watson Jones’ anterolateral approach is chosen. The incision begins 4 cm posterior to the anterosuperior iliac spine, extends up to the tip of the greater trochanter and then parallels the posterior border of the greater trochanter to its inferior margin (Figs 6.13A and B).
The subcutaneous tissue is reflected from the fascia lata, at which point the tensor fascia lata muscle may be seen. The tensor is then reflected anteriorly and the gluteus medius retracted posteriorly. This exposes the anterior hip capsule directly. Then the reflected head of the rectus is cleared of the anterior capsule, and inverted “T” capsulotomy is done which gives direct visibility of the fracture (Figs 6.13C and D).
Figs 6.13A and B: (A) Watson Jones’ anterolateral approach incision; (B) Incising tensor fascia lata
Figs 6.13C and D: (C) Interval between TFL and gluteus medius; (D) Anterior joint capsule and tendon of rectus femoris
Avoid retractors over the 68superior neck to protect the femoral head blood supply. Traction followed by manipulation reduces the fracture (Fig. 6.15). A Kirschner wire is placed in the femoral head and used as joystick to move the femoral head for perfect alignment with the femoral neck. Once the fracture is reduced it is provisionally held in position by pointed reduction clamp (Fig. 6.16A). Subsequently, the fracture should be fixed as described earlier.
Another incision described is Smith Peterson transverse part of incision on the head directly, open tensor fascia and vastus interval and go to capsule, and do capsulotomy (Figs 6.14A to D).
Figs 6.14A and B: (A) Smith Petersen anterior approach incision; (B) Incising deep fascia
Figs 6.14C and D: (C) Internervous plane between sartorius and TFL; (D) Deep internervous plane between rectus femoris and gluteus medius
69
Fig. 6.15: Patient while on traction in OT along with diagram
 
Surgical Procedures
 
Multiple Cancellous Screws (Parallel Cancellous Screws)
The mechanism for stabilization by parallel cancellous screws in a triangular or inverted triangular configuration is commonly performed in young patients (Figs 6.17 and 6.18).
The radiolucent fracture table allows gentle manipulation and proper reduction of the fracture to maintain appropriate fracture position during internal fixation. Usually, three parallel 6.5 cancellous screws with short threads of 16 mm or cannulated cancellous screws are used for fixation.3739 All these multiple screws should be inserted starting from the point just above the level of the lesser trochanter to prevent subsequent stress fractures.4042 The parallel screws are passed in inverted triangle configuration, the first lag screw runs along the calcar in the inferior part of the neck of the femur in AP view and central in lateral view.70
Figs 6.16A to C: (A) Operative X-ray showing open reduction and temporary fixation of fracture fragments which are held in position by towel clip; (B) Diagrammatic representation of multiple cancellous screws; (C) Operative X-ray showing step-wise diagrammatic representation of multiple cancellous screws
Followed by posterosuperior screw as close as possible to the posterior cortex of the neck in lateral view and central in AP view, and third screw in the anterosuperior part in the center of the neck peripherally in the head of the femur (Figs 6.16B and C). If posterior comminution is more a few authors prefer to put a fourth screw in the posterior portion.4344
Closed reduction in perfect position is the key to success and is an important factor in reducing the risk of osteonecrosis and nonunion.45
There is no uniform agreement on what is the acceptable reduction. A varus reduction is known to result in the increased incidence of nonunion whereas a valgus reduction achieves bony stability at the fracture (Figs 6.17 and 6.18). Anatomic reduction allows maximum opportunity for re-establishment of the vascular supply and also prevents the stretching of the vessels in the ligamentum teres. Anatomical reduction is always aimed and 71if it is not obtained by closed reduction, open reduction must be performed. Best acceptable closed reduction is always inferior to anatomical open reduction. Never accept the reduction unless anatomical and open reduction may be required more often than it is done. The incidence of osteonecrosis is not increased if open reduction is performed by anterior approach.
 
Sliding Hip Screw
It is another form of osteosynthesis used for fixation of fracture neck femur in young adults, with a high rate of success. In addition to sliding hip screw (SHS), a derotation screw is placed above earlier to prevent rotation of the femoral head while inserting the large-diameter lag screw of SHS. There is only one report on experimental work which says thick DHS increases the rate of avascular necrosis.
Fig. 6.17:
72
Figs 6.17 and 6.18: X-ray showing subcapital fracture treated by three parallel screws by percutaneous method, preimmediate postoperative, and at the end of 6 months showing good bony union
This view is not substantiated by other workers. Four screws occupy as much space as one DHS and one 7 mm cancellous screw. As a rule use three screws in undisplaced fractures and use DHS with antirotation screw in all displaced fractures with two-hole side plate. After passing the derotation screw the lag screw is passed, over which barrel plate is passed and fixed to the shaft by side plate and cortical screws. We have almost changed over to DHS and one antirotation screw (Figs 6.19 and 6.20).
Most authors agree that in younger patients, transcervical fracture is due to high-velocity injury in which almost always open reduction is needed for best function. DHS with derotation screw is the treatment of choice in this younger age group. The same treatment consideration is given to the group 73of patients who are of higher demand old individuals between the age group of 60 to 70 years but are physiologically much younger, where preferably fracture neck femur is treated by osteosynthesis with excellent results.4955
Fig. 6.19: X-ray showing subcapital fracture treated with sliding hip screw preoperative, postoperative, at the end of 6 months showing good bony union
Fig. 6.20: X-ray showing cervicotrochanterical fracture treated with sliding hip and derotation screw
Many authors have suggested, as an integral part of initial surgery, the capsular release of the hip joint to reduce the intracapsular pressure to reduce the incidence of avascular necrosis of the femoral head.1827 This is also debated and there is no uniform acceptance of this.56 In the younger age group osteosynthesis is the preferred method; however, replacement of the femoral head would be the treatment of choice for displaced fracture neck femur in the elderly individuals. There are reports which suggest that in the borderline group of 60 years and above, it is better to do cemented or noncemented total hip replacement which gives perfect pain relief and is long-lasting with modern day bearing surfaces like ceramic on ceramic, metal on cross-link poly.74
The repeat surgery rate is higher with osteosynthesis compared to replacement and total hip replacement appeared better than hemiarthroplasty.57 The best result of osteosynthesis is inferior to the average result of replacement.58 Results of primary replacement are much better than secondary salvage replacement.5759 The revision rate in several randomized studies has ranged from 33 percent (Ravikumar and Marsh 2000)60 to 58 percent (Roden et al. 2003).61 Many authors recommend hemiarthroplasty as a safe method of treatment in the elderly (Bjorgul K and Reikeras O).62 Hemiarthroplasty in worst cases is better than internal fixation in best cases of displaced femoral neck fractures. In their series the prospective study of 683 patients treated with internal fixation or primary hemiarthroplasty with a follow-up of one to six years concluded that even when treating only the fractures with the assumed best healing potential with internal fixation, the results are inferior to hemiarthroplasty. When there is no hesitation in doing replacement in failed osteosynthesis, then why is there hesitation in doing primary replacement.
 
Primary Abduction Osteotomy
Young patients with displaced fracture with high degree shearing fractures like Pauwels’ Type III with angle beyond 70° have a poor prognosis even if fixed properly.63 In this group of selected patients, there is scope for primary abduction osteotomy to convert the shearing forces into compression forces across the fracture site. There is no evidence that these fractures will not unite if fixed well in anatomical position. If age is borderline it may be a better idea to do total hip in these fractures. In young patients it is very helpful to fix with valgus osteotomy (Figs 6.21 and 6.22). No doubt that this osteotomy is commonly performed for nonunion fracture neck femur in young patients where replacement is not the choice of treatment.64
Fig. 6.21: X-ray showing fresh subcapital fracture treated by primary valgus osteotomy and fixation by DHS and derotation screw
75
Fig. 6.22: Diagrammatic planning for abduction osteotomy, a patient's X-ray at the end of two years
Primary valgus osteotomy is also an issue which is debated. Some do it while others feel that this vertical fracture will unite if perfect reduction and DHS with derotation screw is done. Osteotomy is only reserved for nonunion. Point against osteotomy is that if fracture unites and develops avascular necrosis and needs replacement, osteotomy will make replacement more difficult and may compromise the final result.
Preoperative planning by tracing on the paper is necessary to decide how much wedge should be excised with the base on the lateral side, so as to convert shearing forces to compression forces at the fracture site by valgus osteotomy. Calculate the exact size of the wedge. After necessary anesthesia shift the patient onto the fracture table, under traction reduce the fracture by closed reduction. If closed reduction fails, go ahead with open reduction. Introduce the DHS at the level of the lesser trochanter, ending up in the inferior part of the neck and head, and not in the center. After good fixation of the head with DHS, perform the transverse osteotomy as per preoperative planning just at the point of insertion of hip screw at the level just above the lesser trochanter. Then excise the wedge as per the preoperative calculation, with its base laterally by another oblique osteotomy just below the transverse cut, to convert the fracture line to about 30 to 40° angle. Attach the side barrel plate to the DHS and close the osteotomy by abducting the limb, and finally fixing the screws through the plate by using Müller's compression device. Reconfirm that the desired angle correction is achieved and osteotomy is well in contact and under compression. Patient should be mobilized with partial weight-bearing at the earliest or in two to three days. Instead of regular DHS plate one can use double-angle blade plate specially prepared to be used on DHS, as shown in Figures 6.38 and 6.39.
For preoperative planning of 120° blade plate, tracings should be made of the AP X-ray of the hip. The osteotomy has to be planned at the level of 76the upper border of the lesser trochanter. Approximately 25 to 30° of the wedge is planned. Postoperative drawings are made after wedge resection, and 120° blade plate is used (Fig. 6.22). The entry point is 2 cm proximal to the osteotomy cut on the proximal fragment on the traction table; vastus is incised transversely and reflected. Point of entry of blade plate is marked and guidewire is passed in the desired direction according to preoperative planning. Seating chisel is used to make the passage for the blade with constant visualization in C-arm image. Planned osteotomy is now marked with 2 K-wires and checked. Wedge is removed with cutting saw, keeping proximal cut parallel to the upper end. Do not cut fully ¾ is cut and now seating chisel is removed and replaced with blade plate. Wedge is completed and confirmed in C-arm. Now the lower end is abducted till the wedge is closed, and the distal shaft comes on the plate of blade plate. Compression is achieved with tension device and screws are put in lower end. The wedge bone is used as graft in osteotomy. The final position is confirmed on X-ray before closure.
 
Hemiarthroplasty
In general, replacement of femoral head in displaced femoral neck fractures is the standard treatment in the elderly population and is best accomplished with bipolar or unipolar modular prosthesis. Austin Moore replacement arthroplasty is conventionally done as noncemented, nonbone-forming smooth stem endoprosthesis. The bipolar and modern unipolar designs are now in vogue, which differ from one institute to another and have advantages over the earlier nonmodular endoprostheses. The advantages of modular implant (Fig. 6.23), are that neck length of the component can be adjusted to tension the abductors, the offset of the femoral neck can be adjusted without increasing the leg length and the implant can easily be converted to a total hip joint replacement if required.
Fig. 6.23: Diagrams of modular bipolar prosthesis
77
This surgery of replacement arthroplasty is indicated in elderly persons.6083
All of us can proudly show isolated 15 years and 20 years survival of non-cemented Austin Moore replacement (Fig. 6.24). But when all surgeries are compared, the final outcome of noncemented Austin Moore replacement failure in porotic bone becomes evident (Fig. 6.25). Presently, noncemented Austin Moore arthroplasty is only indicated in patients with limited activity or nonambulatory patients with low demand.
Thompson arthroplasty is almost similar to Moore's arthroplasty which is indicated when the femoral calcar is broken. Both Austin Moore and Thompson's arthroplasty if done in a patient as primary surgery with cement can give better results. The results of unipolar and bipolar Austin Moore prosthetic replacement are similar in the literature, there is no difference between cemented unipolar and cemented bipolar hemiarthroplasty.
Fig. 6.24: X-rays of two patients, 20 years and 15 years of follow-up with good results
Fig. 6.25: Serial X-rays of patient showing failure
78
The age-old practice of using noncemented Austin Moore prosthesis is presently debated and better results are achieved with cemented unipolar prosthesis without standard fenestration or cemented bipolar or total joint replacement.
The literature showed that patients with osteosynthesis (Skinner et al.84) had a higher incidence of revision surgery compared to the group of bipolar hemiarthroplasty. Similarly Parker et al.85 and Rogmark and Johnell86 reported a higher rate of reoperation in the patients of open reduction and fixation compared to the hemiarthroplasty group in displaced femoral neck fractures.
 
Total Hip Arthroplasty
Lately, total hip replacement as the treatment of choice has become popular in the active elderly group of patients with displaced fracture neck femur.8797 It has very good predictable long-term results, though it has a high-risk of early dislocation as compared to hemiarthroplasty when 22 mm head is used. Total hip arthroplasty was commonly performed to salvage the complications of femoral neck fractures such as nonunion, osteonecrosis, conversion of endoprosthesis and failure of osteosynthesis. Today total hip arthroplasty is commonly performed for acute fractures of the femoral neck in selected elderly patients. It is indicated in patients of fracture neck femur with preexisting arthritis like rheumatoid or osteoarthritis involving the acetabulum. Patients of rheumatoid arthritis with fracture neck femur have poor union rate, and loss of fixation occurs in a higher percentage of patients, hence, primary total hip arthroplasty is indicated in such patients. The disadvantages of total joint replacement include greater magnitude of surgery, increased blood loss, increased rate of early dislocation, and possibility of increased rate of infection after surgery. Hence, present-day indication of total arthroplasty is for displaced fracture neck femur in the elderly who are very active and statistically are likely to live more than 10 years, patients with preexisting symptomatic hip disease, extremely cooperative patients with excellent mental status, metastatic pathological fracture neck femur involving the acetabulum. Dislocation rate was higher when 22 mm head was used earlier. Now with the introduction of cross-link Poly, ceramic and steel-bearing surfaces, greater size of head has become a reality. The size of the head has been standardized to 28 mm with normal Polly. While with high-grade cross-link polly and ceramic or steel-bearing surfaces, size of the head safely used is 32 and 36 mm and also normal size of the head like 58 and 60 mm can be used as volumetric wear which used to be higher with normal Polly has reduced with introduction of these newer bearing surfaces. With increasing size of the head, dislocation rate in replacement after fracture neck of the femur has also reduced dramatically. High offset implant is preferred to improve the tissue tension when doing total hip in fracture neck of the femur.79
 
Surgical Approach for Prosthetic Replacement
The surgical approach to hemiarthroplasty or total hip arthroplasty could be either anterolateral or posterior. The commonly used approach is posterior southern approach for Austin Moore arthroplasty popularized by Moore (Fig. 6.26).
Surgical approach for Austin Moore replacement: Moore used the posterior approach, called southern approach for insertion of endoprosthesis and it was very popular for hemiarthroplasty. Under anesthesia patient is positioned slightly in the mid-prone position as shown in the Figure 6.26.
Make a slightly curved skin incision centered over the greater trochanter beginning 5 cm below the posterior-inferior iliac spine extending about 8 cm below the greater trochanter along the course of posterior part of the femoral shaft. Divide the fascia in line with the skin incision over the center of the greater trochanter. Bluntly split the gluteus maximums proximally in the direction of its fibers till it reaches fasciotendinous attachment (Fig. 6.26). Bluntly dissect the anterior and posterior edges of the fascia and expose the gluteus medius muscle. Divide the trochanteric bursa and bluntly sweep it posteriorly to expose short external rotators. Maintain the hip in extension, flex the knee and internally rotate the thigh to place the external rotators under tension. Palpate the sciatic nerve, which is in relax position because of extension of hip and keep it away from the field.
Fig. 6.26: Position of patient on the operation table and stages of southern approach (Moore's)
Subsequently, palpate 80the tendinous portion of the piriformis, obturator internus, and gemelli and the proximal half of the quadratus femoris, and place the tag sutures in the tendinous portion for later identification closure. Coagulate the vessels along the piriformis and terminal branches of the medial circumflex within the substance of the quadratus femoris. The short external rotators are cut, separated with superior fibers of the quadratus femoris with the help of electrocoagulation and reflected posteriorly protecting the sciatic nerve. Then the posterior capsule is cut in a T-shaped manner along the axis of the femoral neck which exposes the femoral head and neck. Retract the capsule and preserve it for later repair or excise the visible portion of the capsule. Deepen the fracture cleavage and remove the femoral head with the help of the head extractor. The ligament teres requires division many times before the femoral head can be delivered in the wound. The excised femoral head is measured for selecting the appropriate size of the implant by passing it through the template. Pack the acetabulum with sponge, to avoid spillage of tiny bony fragments and then prepare the femoral shaft. Mark the level and angle of the proposed osteotomy of the neck or trim the neck about 2 mm up from the tip of the calcar. Expose the proximal femur in the operative field by markedly rotating the femur internally, so that the tibia is perpendicular to the floor (Fig. 6.27).
Allow the knee to drop toward the floor and push the femur proximally. Remove any remaining soft tissues from the posterior and lateral aspect of the neck. Remove slight portion of bone from the lateral aspect of the femoral neck to get access to the center of the femoral canal. With the box chisel remove the bone from the greater trochanter to gain access for axial reaming of the femoral canal.
Fig. 6.27: Operative steps of Austin Moore replacement. Position of limb during reaming
81
Adequate bone should be removed from the medial aspect of the greater trochanter to maintain valgus position of the implant and to avoid varus position. Reaming of the femoral canal should be started by small tapered hand reamer followed by use of a large reamer with flat ends, as shown in Figure 6.28.
Proceed with progressively large reamers until firm cortical reaming is felt. Assess the stability of the axial reamer within the canal, where no deflection of the tip of the reamer in any plane should be possible. Now proceed with the preparation of the proximal femur after removing the residual cancellous bone from the medial aspect of the neck. Begin with a broach 2 mm smaller than the last used reamer, precisely in the same alignment as the reamer. Rotate the broach to control anteversion and align it to precisely match the femoral neck. Maintain precise control over anteversion, as the broach is gently impacted down the femoral canal, till the cutting edge of the broach reaches the cut edge of the neck (Figs 6.29A to D).
Seat the final broach at a point where it is stable axially and will not advance further even with mallet. Once this is achieved the femoral canal is ready for inserting the selected appropriate size of the Austin Moore prosthesis. If for any reason adequate stability is not achieved, then use cement for fixation (Figs 6.30A to D). Insert the Austin Moore prosthesis and confirm the perfect fit of prosthesis with proper anteversion.
Fig. 6.28: Method of reaming after proper entry into the femoral canal and maintaining proper rotation
Figs 6.29A to D: Operative steps of sequential reaming
82
Figs 6.30A to D: Operative steps of sequential reaming, cementing and fitting of prosthesis
Figs 6.31A and B: X-ray showing displaced subcapital fracture in a 70-year-old male treated by Austin Moore's hemiarthroplasty
Remove the pack from the acetabulum, irrigate the acetabular cavity and clean it. Then reduce the hip by gentle traction in flexion of hip and rotation, at times by using plastic-covered pusher to reduce the head into the socket. Then look for the stability of the hip by rotating the femur, and flexion extension movements of the hip.
After reduction of the hip proceed for the repair of the posterior soft tissue of the hip, capsule and short external rotators. Reattach the external rotators directly to the bone at times by drilling the holes made by towel clip or drill. Insert the suction drain and repair the separated gluteus maximums and fascia lata while keeping the hip in abduction. Careful repair of soft tissue envelope helps in stabilization of hip. Close the subcutaneous layer and skin (Figs 6.31 and 6.32).
The posterior approach has historically been associated with a high incidence of posterior dislocation in the postoperative period. This approach should be avoided in patients with flexion adduction contractures to avoid increased incidence of postoperative dislocation, and instead these patients 83should be operated by anterolateral exposure.
Figs 6.32A to D: X-ray showing displaced subcapital fracture in a 67-year-old female treated by cemented bipolar replacement
Lately, a few workers have used the anterolateral approach since it has better stability because of the intact posterior capsule, and fewer disturbances to the abductor mechanism. Hardinge98 has described a lateral incision for the anterolateral approach to the hip, which is parallel to the femoral shaft and centered over the greater trochanter. This exposure can be used for hemiarthroplasty or total hip replacement (Figs 6.32 to 6.34).
There might be rare incidence of a combination of fracture neck femur with dislocation of hip or fracture of femoral head. The fracture neck femur should be treated surgically either by fixation or prosthetic replacement depending upon the merit of each case. There may be fracture of femoral head Type I or II along with fracture neck femur (Type III of Pipkin's classification of fracture femoral head). In such situations there is marked instability, and vascularity is impaired.
In these Type III fractures, there are three elements of injury, dislocation of hip, fracture femoral head and fracture femoral neck. Surgical treatment is mandatory for fixation of fracture neck femur and stabilization of femoral head fragment or one may consider primary total hip joint replacement (Figs 6.35 and 6.36).84
Figs 6.33A to C: X-ray showing subcapital fracture neck femur in an active 75-year-old male treated by primary cemented total hip replacement
Figs 6.34A to C: X-ray showing subcapital fracture neck femur in an active 65-year-old male treated by primary uncemented total hip replacement
85
Figs 6.35A and B: X-ray showing Pipkin Type III injury
Figs 6.36A to F: X-ray showing subcapital fracture neck femur with posterior dislocation of hip in a young active 52-year-old male treated by open reduction and parallel screw fixation
 
Complications
There are various complications associated with fracture neck femur. The complications may be early or late (Table 6.1).86
Table 6.1   Complications of femoral neck fractures
Sr. No
Early
Late
1.
Mortality
Nonunion
2.
Infection
Osteonecrosis
3.
Deep venous thrombosis and pulmonary embolism
Heterotopic ossification
4.
Dislocation
Painful hip
5.
Loss of fixation
Shortening of limb
 
Mortality
The early mortality rate in the elderly population after fracture neck femur during the first year is very high. It varies a lot, Zuckerman et al.99 reported 15 percent, Rodriguez et al.100 Homberg et al.101 Aharonoff et al.102 and Christopher Moran103 reported between 14 to 30 percent. White et al.104 Brown et al.105 Miller CW106 and Holt et al.107,108 reported between 8 to 47 percent. The risk of mortality is highest during the perioperative period, which gradually reduces. Several factors affect the mortality rate, including age, sex, comorbid conditions, level of pre-injury functioning and presence of associated renal disease. In spite of improved fixation techniques and early rehabilitation with quick return to domestic environment the perioperative mortality rate is around 5 percent.
 
Infection
Infection at the operative site is another complication, though prophylactic antibiotics have reduced the risk of infection. If fracture neck femur gets infected after surgery, it is likely to spread to the hip joint and the fracture may not unite. Salvage of the femoral head is unlikely in this situation. The incidence of postoperative sepsis is reported up to 5 percent.109,110 Late deep infections are more difficult to detect. Unusual pain, prosthetic dislocation, persistent thigh swelling, elevated erythrocyte sedimentation rate (ESR) and radiological evidence of bone erosion are suggestive of infection. Acute infection in the immediate postoperative period should be tackled by early exploration, incision drainage, and thorough debridement along with intravenous antibiotics. This may salvage the prosthetic replacement. Whereas in late infection the prosthesis needs removal and hip should be treated by Girdlestone operation.
 
Deep Venous Thrombosis
Pulmonary embolism is the fourth most common cause of death in hip fracture patients. Rarely, bleeding can be a major problem if prophylaxis is 87not undertaken. Without prophylaxis, the risk of deep venous thrombosis has been reported to be greater than 50 percent and of fatal pulmonary embolism 0.5 to 2 percent. The review of prophylactic treatment for prevention indicates:
  1. Aspirin has a relative risk reduction of 29 percent
  2. Regular heparin has relative risk reduction of 29 percent
  3. Low molecular weight heparin has relative risk reduction of 44 percent
  4. Warfarin has relative risk reduction of 48 percent.
The duration of prophylaxis is controversial. Studies from North America indicate that clinically relevant deep venous thrombosis occurs in only 3 to 4 percent of patients receiving warfarin or low molecular weight heparin after 7 to 10 days in the hospital. Fatal pulmonary embolism occurred in only 0 to 08 percent of patients. In practice low molecular weight heparin once a day should be instituted after the patient's admission and continued till the patient is discharged, for a period of 7 to 10 days. The majority of fractured hip patients are discharged without any prophylaxis at home.
 
Dislocation
The rate of dislocation after replacement arthroplasty varies in reported series, and is reported between 0.3 to 10 percent.7274 Though rare, factors associated with dislocation include excessive anteversion or retroversion of prosthesis, posterior capsulectomy, excessive postoperative flexion or rotation with hip in adduction. Postoperative infection is also one of the common causes of dislocation. Once the dislocation is diagnosed closed reduction under sedation or general anesthesia is indicated. If several attempts at closed reduction fail, open reduction is indicated. After reduction traction for a few weeks and bracing in abduction and limiting the flexion upto 70° for six to eight weeks till good soft tissue healing occurs is desirable and recommended.
 
Loss of Fixation
Fixation failure usually is evident during the early postoperative period. A patient with unstable fixation complains of pain in the groin and buttocks with or without pricking sensation. The repeat X-rays may confirm displacement or angulations of fracture and change in the geometry of earlier fixation. Sometimes early fracture fixation is related to posterior comminution but most of the time it is because of poor fixation secondary to nonanatomical fracture reduction or osteoporosis. There might be technical failures in fixation, such as malreduction, short screws, threads not crossing the fracture site, widely divergent screws, etc. Early fixation failure within three months after surgery occurs in 12 to 24 percent of displaced fracture neck femur.101,109112 All workers found age and inaccurate fixation as the 88main causes of loss of fixation. The importance of anatomic reduction has been well documented in the literature.109
In view of loss of reduction and failure of fixation, the choice of treatment depends upon the age, functional demands, medical condition and presence of osteoporosis. When all these factors are favorable in an active young patient, the surgeon should proceed with revision of open reduction and internal fixation. Abduction (valgus) osteotomy can also be considered. Whereas in elderly persons with poor bone quality and lower functional demand total hip replacement or hemiarthroplasty should be the treatment of choice (Figs 6.44, 6.45, 6.47).
 
Nonunion
Early fixation failure within three months after surgery occurs in about 12 to 24 percent of displaced fracture neck femur. Fracture neck femur has a very high incidence of nonunion, which occurs in as many as 20 to 30 percent of patients with displaced fractures, though it is rare in undisplaced fractures.99101 There is a constant race between the healing of fracture and failure of fixation leading to nonunion. Fracture neck femur usually unites within six months, and if there is no evidence suggesting healing, or the patient continues to have pain at four to six months after fixation then it is presumed to be a nonunion. One has to differentiate between nonunion and osteonecrosis at this stage, since both conditions are different; osteonecrosis is based on the insufficient vascular supply within the femoral head, whereas nonunion is based on the failure of the healing process. There is direct correlation between poor fracture reduction and fixation with rate of nonunion, since poor quality of reduction directly affects the union. Posterior comminution of femoral neck, severe osteoporosis and shearing stresses commonly seen in the fracture neck femur with a vertical inclination increases the risk of failure of union.
The options for the treatment of nonunion include revision of osteosynthesis after fracture reduction, valgus osteotomy to add compression to the fracture site, Meyers’ posterior pedicle bone grafting,113 abduction osteotomy,64 quadratus femoris muscle pedicle grafting,114,115 free fibular grafting116,117 and arthroplasty.8897
Many authors have used the procedure of Abduction (Pauwel's) Osteotomy64 as salvage for nonunion neck femur in young adults (Figs 6.37 to 6.42). The basic principle is to improve the biomechanics by conversion of shearing forces to compression forces at the nonunion site with compression by osteosynthesis (Fig. 6.43). After calculating the desired wedge from the lateral side in the intertrochanteric region the osteotomy is stabilized by double-angled blade plate, or modified DHS or any other implant to achieve compression at nonunion site and also at the site of the osteotomy (Figs 6.39B and C).
Similarly, to improve the biology, many authors have performed the procedure of bone grafting113117 in addition to osteosynthesis.89
Figs 6.37A and B: (A) X-ray showing Pauwel's Type III transcervical fracture neck femur, nonunion in an active 50-year-old. The fracture had nonunion and bony union was achieved by abduction osteotomy and stabilization by special double-angled blade plate; (B) The operative steps of abduction osteotomy
Figs 6.38A to C: X-ray showing Pauwel's Type III fracture neck femur in a young male initially treated by osteosynthesis with implant failure and nonunion. The bony union was achieved by abduction displacement osteotomy and stabilization by special double-angled DHS (shown in Fig. 6.39)
Figs 6.39A to C: (A) X-ray showing fracture neck femur treated by abduction displacement osteotomy and stabilization by double-angled blade plate; (B and C) Showing implants—plates used for stabilization after abduction displacement osteotomy
90
Figs 6.40A to F: X-ray showing 7 months ununited subcapital fracture left hip treated by valgus osteotomy and fixation by DHS and derotation screw
Figs 6.41A to D: X-ray showing Pauwel's Type III fracture neck femur in a young male with nonunion. The bony union was achieved by abduction displacement osteotomy and fixation by DHS, derotation screw. X-ray showing nonunion, 3 years postoperatively after abduction osteotomy and last X-ray after removal of implant
A lot of publications have reported excellent results by use of free fibular grafting and additional stabilization by cancellous screws. Nagi et al.116,117 have reported a series of nonunion treated by free fibular graft with good results. Meyers et al.113 reported the use of the quadratus femoris muscle pedicle graft in patients less than 40 years of age who sustained fracture neck femur.
 
Muscle Pedicle Grafting (Meyers)
Meyers reported the use of vascularized muscle pedicle graft by using the quadratus femoris along with bone block for displaced fracture neck femur with comminution.113 The graft was used to improve the stability of fixation and increase the local vascularity to reduce the risk of nonunion and osteonecrosis. Baksi DP has also reported good results when osteosynthesis 91was coupled with quadratus femoris grafting for ununited fracture neck femur.114,115
Figs 6.42A to E: X-ray showing Pauwel's Type III fracture neck femur in a young male initially treated by osteosynthesis, with nonunion. The bony union was achieved by abduction displacement osteotomy and stabilization by angled blade plate
Figs 6.43A to F: X-ray showing Pauwel's Type III fracture neck femur in a 58-year-old male initially treated by multiple cancellous screws showing nonunion with implant failure and penetration into the joint. The painful hip was treated by hybrid total hip replacement
92
He reported 75 percent union rate in a series of 56 femoral necks’ nonunion when treated by this technique. The role of muscle pedicle grafting in the treatment of femoral fracture neck femur is not very clear. However, it can be considered as an alternative treatment in young individuals who sustain fracture neck femur with posterior comminution or fracture, which develops nonunion.
 
Surgical Technique
The patient after necessary anesthesia is positioned on a radiolucent table in prone position. A posterior approach to the hip is performed similar to lower half incision of the southern approach. After incising the fascia lata, vastus lateralis, and aponeurotic lower portion of the gluteus maximus, the short external rotators of the hip are exposed. The piriformis, Gemelli, obturator and quadratus femoris muscle are identified. The quadratus femoris muscle is delineated and a bone block incorporating its tendon is harvested from the posterior portion of the greater trochanter. Subsequently, the posterior hip capsule is incised, fracture reduced and confirmed under image intensifier. Finally, the fracture is fixed with multiple cancellous screws. The defect in the posterior femoral neck because of comminution is appropriately shaped to fit the bone block and packed by cancellous bone graft (Fig. 6.46). The bone block with the quadratus femoris muscle is inserted into the prepared trough and stabilized by 3.5 or 4.5 mm screw. The wound is closed in layers after keeping the suction drain.
We have given up doing this procedure now as it gives inconsistent results and makes replacement more difficult with compromised result. Abduction osteotomy is the only procedure done by us for young patients having nonunion. Even in the 50 years’ age group total hip is the treatment of choice due to its better result and improved joints, giving longer survival rate.
The treatment for nonunion in the elderly population is replacement arthroplasty (Figs 6.44, 6.45, 6.47). The type of arthroplasty is consistent with the patient's age, physiological function and quality of bone. Patients with good physiology, independent, with good life span should have the option of total hip replacement and elderly persons with confused state, and uncooperative with poor expected life expectancy should have hemiarthroplasty.
 
Osteonecrosis
The incidence of osteonecrosis following undisplaced fracture neck femur has been reported to be as high as 15 percent,5,1012,25 but in contrast in displaced fractures it is reported as being between 9 percent and 35 percent. Osteonecrosis of femoral head after fracture neck femur is one of the major 93complications, secondary to ischemia as a result of primary injury.118120
Figs 6.44A to D: X-ray showing multiple cancellous screws with implant failure and nonunion. The painful hip was treated by hybrid total hip replacement
Figs 6.45A to D: X-ray showing nonunion following DHS with derotation screw treated by total hip arthroplasty
Subsequently, it results in collapse of subchondral bone and attrition of articular cartilage. If only the small segment is affected with avascular necrosis then with minor pains, the patient can carry on (Figs 6.48A and B). But if a major part of the head is affected, replacement will have to be done (Figs 6.49 and 6.50).94
Fig. 6.46: Diagrammatic representation of Meyers’ procedure in lateral view
Figs 6.47A to D: X-ray showing multiple cancellous screws with nonunion with implant failure and penetration into the joint. The painful hip was treated by uncemented total hip replacement in a young 56-year-old male
This collapse results in joint incongruity, pain and eventually secondary arthritis. These sequential changes occur within two years of fracture which results in disabling painful stiff hip and shortening (Figs 6.51A and B). The incidence of osteonecrosis in nondisplaced fractures is about 11 percent 95and the incidence increases as the fracture becomes more displaced and is reported between 20 and 35 percent.
Figs 6.48A and B: Post-traumatic osteonecrosis following fixation with three cancellous screw with minimal affection and step deformity, noticed after 2 years of surgery
Figs 6.49A and B: X-ray showing old healed fracture neck femur with osteonecrosis of femoral head with multiple cancellous screws with painful hip which was treated by articular surface total hip replacement in a young 50-year-old male
Figs 6.50A and B: X-ray showing transcervical fracture neck femur with nonunion and osteonecrosis of femoral head following multiple screws fixation with painful hip which was treated by cemented total hip replacement in a male of 63 years
96
Figs 6.51A and B: Stabilization by osteosynthesis in excessive valgus position, patient developed osteonecrosis
The osteonecrosis might affect the entire femoral head, or there might be partial or segmental involvement, depending upon which part of the vascular tree is insulted. The incidence of osteonecrosis might go up to 66 percent in displaced fracture neck femur. Late segmental collapse has been reported as late as 17 years after femoral neck fracture, though 80 percent or more of segmental collapse will occur within two years. The incidence of late segmental collapse is higher in Garden III and IV displaced fracture neck femur and varies from 9 to 35 percent. Vascularity of the femoral head after fracture neck femur depends upon the preservation of the remaining vascular supply and revascularization repair of the necrotic area before collapse of the necrotic segment occurs. In widely displaced fractures all vessels within the neck and retinacular vessels are disrupted and femoral head survival depends on the vessels through the ligamentum teres and the anastomosis between these vessels and lateral epiphyseal vessels. Anatomic reduction and stable internal fixation.
Fixation is a major factor that helps in preserving the remaining blood supply and provides enough stability for the revascularization buds to grow into the area of necrosis and across the density. This density may be secondary to new bone being laid down on necrotic tissue, which produces absolute increase in density, or a relative increase in the density owing to disuse osteoporosis in the surrounding vascular bone and calcification present in the necrotic marrow. The X-ray appearance in the late segmental collapse results in the flattening, fracture in the subchondral bone and collapse of the femoral head resulting in incongruity and arthritis. The early diagnosis 97if suspected can be confirmed by magnetic resonance imaging (MRI) and bone scan.
The treatment in the elderly group of patients is conversion to total hip arthroplasty, or hemiarthroplasty, which are dependent on the patient's age, level of physical activity and comorbidities. Mild small sectoral involvement in osteonecrotic patient can carry on with minimal pain for long-time, if further collapse does not occur.
 
Heterotopic Ossification
Periarticular ossification after prosthetic replacement has been reported to occur in about 25 to 40 percent of patients, though its significant interference in the hip function occurred only in a few patients. In the unusual instance, hip motion might be markedly affected where surgical excision of ossification may be indicated. Prophylactic use of Indomethacin and bisphosphonates can be considered to minimize or avoid heterotopic bone formation.
 
Painful Hip (Table 6.2)
Painful hip after fracture neck femur could be due to many causes. Painful nonunion, shortening, secondary arthritic changes, failed protruding implants, infection, etc. However, a very common complication after endoprosthetic replacement is pain. There are many causes.
Hemiarthroplasty is a very good surgery for the patient. It can cause complications in a small minority of the cases. Loosening, if it occurs, is generally seen in the first two years. Successful hemiarthroplasty can cause acetabular erosions giving pain over seven or eight years (Figs 6.52A and B). Even breaking of the prosthesis is observed in a small minority of cases and all these may need revision of the painful Austin Moore prosthesis (Figs 6.53A to D).
Figs 6.52A and B: X-ray hip showing erosion of acetabulum
98
Figs 6.53A to D: Two X-rays showing broken prosthesis
Table 6.2   Causes of painful hip
Causes of painful hip
1. Acetabular erosion
6. Dislocation and fracture
2. Protrusion acetabulii
7. Infection
3. Loosening
8. Periprosthetic fracture
4. Thigh pain
9. Myositis ossificance
5. Breakage/perforation
10. Absorption of medial femoral cortex
To salvage this painful Austin Moore (AM) replacement one has to be careful and needs accurate planning for removal of AM prosthesis (AMP).
Steps in removal of AMP: In a patient with chronically painful AMP the hip capsule is contracted with stiffness of hip. This capsule needs complete removal (Fig. 6.54). It is a pseudocapsule which has formed around the prosthesis. Unlike a normal capsule this is hourglass in shape hugging the prosthesis all around and needs to be completely excised first to explore the metal surface completely. The complete round surface of the prosthesis should be seen. This may have to be excised more and more during surgery, if dislocation is unsuccessful after removing the capsule, initially. The hole provided at the top of the prosthesis is the most important tool to remove the prosthesis and should be fully exposed to introduce the hook inside this hole.
This hook now plays the key role in removing the prosthesis. Pull the prosthesis out of the acetabulum with this hook by gently giving traction through this hook vertically outside. You will be able to see increasing movements as the capsule is being excised progressively. Do not try to lever out the prosthesis by rotating the leg as this will be unsuccessful and will result in fracture of the shaft. Bring out the head a little to the edge of the 99acetabulum by tugging on the hook in the proximal hole, then only minimal movement of the limb will be helpful to dislocate the head.
Fig. 6.54: X-ray showing Austin Moore prosthesis perforating through the shaft
Figs 6.55A to D: Operative steps for the removal of AMP
This is helped by putting two levers in the acetabulum, one proximally and one distally, to lever out the head along with the hook which is already in the proximal hole. New bone formation at the tip of the prosthesis will have to be removed with the gouge around the corner to clear the new bone to see that it is now clear for removal of the prosthesis (Figs 6.55A to D).
If the implant is broken, it can be removed by two hooks and two skids as in Figures 6.55A to D.
At times there is new bone formation in the AMP holes as in the Figure. This bone needs to be removed with C–arm-controlled, like interlocking locking technique, by drilling in the bone in the hole and breaking the bone island in the hole (Figs 6.56A and B).
Periprosthetic fracture can be one of the infrequent complications of AM replacement arthroplasty. It needs surgical treatment of stabilization by multiple cerclage wires,or by locking compression plate (LCP) (Figs 6.57A to D). It will be worth converting into long stem total hip arthroplasty if patient 100had difficulty in walking and pain before the fracture, or if the AMP is loose as seen in the X-ray.
Figs 6.56A and B: Operative steps under image intensifier
Figs 6.57A to D: (A and B) Periprosthetic fracture of the shaft of femur just below the tip of AMP; (C and D) Stabilization of periprosthetic fracture with LCP and cerclage wires
101
 
Conclusion
For all practical purposes fracture neck femur should be grouped into three categories to suggest the surgical line of treatment depending upon their age, quality of bone and physiological function.
  1. Femoral neck fractures in young adults have been considered as a separate entity which occurs in normal bone and are relatively uncommon. The recommended management for these fractures has been distinctly different from that for the elderly group. Anatomic reduction and stable fixation should be performed as early as possible though this group has a high percentage of the complications of osteonecrosis and nonunion. If an attempt at closed reduction fails surgeon should directly proceed for an open reduction through anterior approach. Swiontkowski et al. reported a series of patients of fracture neck femur between the age of 12 and 49, who were treated by open reduction and fixation by 6.5 mm cancellous screws within 8 hours with 100 percent unions. All fractures united but 20 percent of patients developed osteonecrosis. They recommended that the fracture neck femur in young active individuals be treated as an orthopedic emergency and fracture should be stabilized as soon as possible, once the life-threatening injuries have been managed.
  2. Fracture neck femur in the elderly population can be divided into two subgroups. The first group of patients who are beyond 60, 65 years and are very active and physiologically much younger should be managed by osteosynthesis. Whereas the other elderly group of patients should be treated with hemiarthroplasty or total hip replacement. Hip replacement in patient above 60 years is a very attractive option when compared with the results of well-healed fracture and salvage hip replacement.
  3. This fracture has a lot of complications, especially nonunion and osteonecrosis. Fracture neck femur has a very high incidence of nonunion, which occurs in as many as 20 to 30 percent of patients with displaced fractures, though it is rare in undisplaced fractures.98100 The incidence of osteonecrosis following undisplaced fracture neck femur has been reported as high as 15 percent5,1012,25 but in contrast in displaced fractures it is reported as being between 9 to 35 percent. Closed reduction in perfect position is the key to success and is an important factor in reducing the risk of osteonecrosis and nonunion.45
 
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Intertrochanteric Fractureschapter 7

The goal of treatment of any intertrochanteric fracture is to restore mobility safely and efficiently while minimizing the risk of medical complications and technical failure and to restore the patient to preoperative status. There are multiple factors and variables,1,2 which affect the biomechanical strength of repair. Surgeon-independent variables are bone quality, which is related to age and osteoporosis and fracture pattern and fracture stability. Surgeon-dependent variables are quality of fracture reduction and choice and placement of implant. Unstable intertrochanteric fractures are technically much more challenging than stable fractures; a stable reduction of an intertrochanteric fracture requires providing medial and posterior cortical contact between the major proximal and distal fragment to resist varus and posterior displacing forces. Hence, surgeons must understand the implant options available and should strive to achieve accurate realignment and proper implant placement.
 
Etiology
Most of the hip fractures in the elderly result from a simple fall. This is mainly because elderly people are unable to dissipate energy as compared to young persons. Their protective responses are also diminished because of slow reaction time, weakness, disorientation and the side effects of medications. Elderly people also lack shock absorbers such as pad of fat or muscles over the trochanteric region and have diminished bone strength because of osteoporosis. All these allow fractures to occur with trivial fall.
 
Classification
Although classification is useful for describing intertrochanteric fractures, its utility in predicting outcomes in subgroups is questionable. For years the classification devised by Boyd and Griffin3 was utilized, which is based on fracture pattern and amount of comminution (Fig. 7.1). The classification should serve two purposes, one the possibility of assessment of obtaining the stable reduction, preferably in anatomical position and second the prediction of avoiding secondary collapse and implant failure.109
Fig. 7.1: Boyd and Griffin's classification
Most surgeons prefer to classify the fractures simply as stable and unstable as introduced and popularized by Evans 1949 (Figs 7.2A and B).4 A truly stable intertrochanteric fracture is one which when reduced has a cortical contact, without a gap, medially and posteriorly. Medial cortices of proximal fragment and distal fragment are not comminuted and the lesser trochanter is not displaced. This contact prevents displacement into the varus or retroversion when forces are applied. Whereas in unstable intertrochanteric fracture there is comminution of the greater trochanter and there is no contact between proximal and distal fragment because of displaced posteromedial fragment. There is another variety of unstable fracture—reverse oblique intertrochanteric fracture femur.5 Evan's classification was modified by Jensen and Michaelsen in 19756 and later by Kyle in 1979.7
In Jensen- Michaelsen's classification, decreasing stability is linked to the number of associated lesser and greater trochanteric fragments (Fig. 7.3). Type IA are nondisplaced and Type IB are displaced simple two-part fractures, Type IIA are three-part fractures with a separate greater trochanter fragment, but are stable if medial cortical opposition is obtained, whereas Type IIB fractures are three-part fractures involving the lesser trochanter and are inherently unstable but can be converted to stable reduction if medial cortical buttress is re-established. Type III fractures are four-part fractures involving both the greater and lesser trochanter, which are inherently unstable.
Kyle's four-type classification is based on Evan's system, where Type I are two-part nondisplaced, stable fractures, Type II are stable but displaced into the varus with small lesser trochanteric fragment with essentially intact posteromedial fragment, Type III four-part, unstable fracture displaced into the varus with posteromedial cortical comminution and greater trochanteric fragment; Type IV are similar to Type III fractures but fracture has extension into the subtrochanteric area (Figs 7.4A and B).
There is another rare component of injury, where the inter trochanteric fracture line extends into the neck femur, reported by Kyle8 who had fairly good results when this fracture was treated by SHS (Fig. 7.4B).
The AO/OTA alphanumeric classification incorporates prognosis and suggests treatment for every element of the skeleton, where intertrochanteric 110fracture is designated by Type 31A, and further subclassified into three groups based on the obliquity of fracture line and amount of comminution (Fig. 7.5).
Figs 7.2A and B: (A) Evan's classification; (B) Position of fragments before and after reduction
Fig. 7.3: Jensen and Michaelsen classification
111
Figs 7.4A and B: (A) Kyle's type classification IT fracture; (B) Kyle's Type VI extending into the neck of femur
The size and displacement of the lesser trochanteric fragment is a key to decide the instability of the intertrochanteric fracture. Similarly, intertrochanteric fracture with reversed obliquity5 in which there is inherent tendency of medial displacement of the distal fragment secondary to pull by adductor muscle is also an unstable injury. For planning the treatment and prognosis, there are only few factors to be considered. When the lesser trochanter is not fractured or is not displaced though fractured, they are simple fractures, and will get good results when operated with DHS or reconstruction nails, and will reduce well with simple traction on the table.
The fractures with displaced lesser trochanter and those with large posterior medial fragment involving the lesser trochanter are the fractures which will give poor results on treatment (Figs 7.6A and B).
These fractures may need open reduction and may be candidates for cephalocondylar type (PFN, Gamma or recon type) of fixation for improved results. Four-part fractures where one element is a basal fracture, do not do that well and this needs to be kept in mind while planning treatment. Those fractures in the elderly population above 80 years or with severe comorbidities and comminution in the age group of 70s may be better treated by joint replacement surgery.
 
Management
After detailed preoperative work-up, and correcting immediate medical conditions, patient should be taken up for surgery early, within 48 hours, 112to prevent chest complications and bedsores in this geriatric population.9
Fig. 7.5: AO/OTA classification of proximal femoral fractures
Meanwhile, the extremity should be maintained in a position of comfort, flexed hip and knee supported by pillow. Buck's traction is of very little use.10
 
Surgical Treatment
Usually regional anesthesia is preferred over general anesthesia. Prospective randomized study showed no difference.11,12,2113
Figs 7.6A and B: Displaced lesser trochanteric fragment with a large posteromedial fragment
 
Evolution of Surgical Techniques
Over the last 50 years, the technique of fracture fixation has changed dramatically.
SP nail was the first implant used in 1925.13,14 That was modified with McLaughlin plate, by changing the shape of the plate. Nail and plate were connected with a top screw which worked as weak link and it would come out at times (Figs 7.7A and B).
Then came fixed angle nail plate devised by Jewett which is a triflanged nail fixed to a plate at an angle between130 to 150° (Figs 7.8A and B).15,16 Though this device provided stabilization it did not allow fracture impaction and many times resulted in the penetration of the implant into the hip joint or cut out superiorly from the femoral head. With the unsatisfactory experience with fixed angle nail plate device, newer implants were devised which allowed controlled fracture impaction.
This gave rise to a sliding nail plate device like Massie nail, which consisted of a nail that provided proximal fragment fixation and a side plate that allowed impaction by telescoping of the side plate within the barrel (Fig. 7.9A).17
Figs 7.7A and B: (A) SP nail and plate; (B) SP nail with McLaughlin plate
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Figs 7.8A and B: Jewett nail plate
Figs 7.9A and B: (A) Massie nail; (B) Sliding hip screw
The implant provided controlled fracture impaction with bone-to-bone contact which promoted fracture union.7,9 Implant sliding also decreased the moment arm and stresses on the implant, which lowered the incidence of implant failure.
This sliding nail plate device gave rise to an improved version of dynamic hip screw (sliding hip screw), in which the tip of the screw was blunt with large outside thread diameter (Fig. 7.9B).9,16 More recently, a two-component plate device like Medoff's plate was introduced, in which a central vertical channel constraints an internal sliding component, especially for unstable intertrochanteric fractures18,19 at times achieving biaxial compression (Figs 7.10A and B). Similarly trochanteric stabilization plate has been introduced as an adjunct to side plate to limit shaft medialization, especially in comminuted fractures.20115
Figs 7.10A and B: Medoff plate with compression facility
Intramedullary devices have also been used to stabilize intertrochanteric fractures. Intramedullary implants are subjected to smaller bending moments than eccentrically placed SHS since they are placed closer to the mechanical axis of the femur. There are various types of intramedullary implants, condylocephalic, or cephalomedullary like Ender's nail, and reconstruction nails. The advantages of Ender's nailing was minimal blood loss, minimum operating time and reduced mortality, but in actual use it was associated with a significant incidence of complications like rotational deformity, migration and cutting out of nails from the femoral head, supracondylar femoral fractures, back out of the nails with resultant knee pain and stiffness.2123 There were more secondary operations after fracture stabilization for unstable intertrochanteric fractures by Ender's nailing23, 24
The intramedullary devices for stabilization of peritrochanteric fractures have been recently developed, like Gamma nail, Roussel Taylor's nail and PFN (Figs 7.11A and B).2532 Intramedullary devices have many advantages like:
  • Intramedullary device because of its location provides more efficient load transfer than does SHS (sliding hip screw) (DHS) provides
  • Shorter lever arm, which decreases tensile strain on the implant
  • Since the implant incorporates a SHS, it achieves controlled impaction
  • Closed procedure with short operative time
  • Minimal blood loss with less soft tissue dissection.
There have been a lot of prospective and randomized studies comparing Gamma nailing and SHS.2530 Patients whose unstable fractures were stabilized by IMHS had significantly better mobility, better walking ability with less shortening and less screw sliding.
In the absence of stable medial cortical buttress the incidence of implant failure and joint penetration was very high. The choice of surgical fixation depends mainly on whether the fracture is stable or unstable.116
Figs 7.11A and B: Intramedullary device—Gamma nail and PFN
Figs 7.12A to C: Photograph showing three different types of fixation
A stable fracture may be fixed with any implants but the skill lies in the fixation of an unstable fracture, which preferably should be stabilized by one of the types of intramedullary devices (Figs 7.12A to C). However, in few cases prosthetic replacement and total hip joint replacement may be preferred and rarely, external fixator.
All the control studies have not shown any superiority of intramedullary devices like PFN or Gamma nail over DHS.
 
Compression Hip Screw and Side Plate
The compression hip screw remains the standard implant in the management of intertrochanteric fractures in the elderly. The fracture reduction should be assessed by evaluating major fragment translation and angulations between the head neck fragment and the femoral shaft.
Only few millimeters’ translation in AP and lateral plane should be accepted. Acceptable neck-shaft angulations are between 0° of varus and 117valgus up to 15 to 20°. Fracture reduction can be controlled by the surgeon; poor fracture reduction is associated with fixation failure and should not be accepted. Compression hip screw is a two-piece device consisting of a large-diameter cannulated lag screw that articulates with side plate and barrel. Commonly sliding hip screws are available with a plate angle of 135° and 150°. Biomechanical studies have demonstrated that 150° implant facilitates lag screw sliding and it closely approximates the weight-bearing axis which decreases the stress on the implant, but a higher angle makes it difficult to insert the nail in the center of the femoral head and needs a more distal entry in the femoral cortical shaft, rather than in the metaphyseal cancellous bone.20, 3136 This also results in higher stress riser effect at the point of entry. Our preference from our clinical experience is to use 135° plate for all intertrochanteric fractures (Figs 7.13 and 7.14).
Manipulating the extremity with traction to unlock the keyed fragments, and then repositioning the limb will improve reduction. Posteromedial fragment that includes the lesser trochanter is rarely aligned by closed methods; though direct open reduction of these fragments is usually unnecessary. Residual posterior sag of the femoral shaft or apex posterior angulations can be easily improved with external support and by elevating the femoral shaft (Figs 7.15A to C).34
Figs 7.13A to D: X-rays showing displaced intertrochanteric fracture treated by DHS in a 65-year-old lady
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Fig. 7.14: Placement of DHS after reduction. Intertrochanteric fracture
Figs 7.15A to C: Correction of posterior sag by table-based device, crutch or gluteal support
The surgeon must assess the fracture reduction and must be certain about the unobstructed biplanar radiographic visualization of the proximal femur and hip joint (Figs 7.16A to C).
Open reduction should be performed when acceptable closed reduction cannot be achieved. It is mainly the lateral view where deficient reduction is noticed, and hence good lateral view is mandatory.119
Figs 7.16A to C: Intertrochanteric fracture treated by LCP, trochanteric plate, IMHS
Figs 7.17A and B: X-rays showing unreducible intertrochanteric fracture and initial poor fixation by DHS implant, which was revised by open reduction and removal of entrapped tendon of iliopsoas. Photographic diagrammatic representation of entrapped tendon of iliopsoas (Said et al.37)
Standard lateral exposure, splitting vastus lateralis, to have access to the anterior part of the fracture is necessary for open reduction. Direct manipulation of the fragments is required to reduce the fracture. Sometimes, there is entrapment of the tendon of the iliopsoas muscle between the vertical fragment of the proximal femur and the lesser trochanter,37 which necessitates open reduction and removal of the entrapped tendon as shown in Figures 7.17A and B.
 
Technique of DHS Fixation
After exposing the lateral aspect of the proximal femur and clearing off the soft tissues, the vastus lateralis is detached from the trochanteric ridge by cutting it posteriorly and it is reflected anteriorly. Reflected soft tissues are held away by a pair of Homan's retractors. Under image intensifier, a starting 120point is identified on the lateral cortex, which is usually at the level of the lesser trochanter, centered equally between the anterior and posterior cortical margins. One should place a guidewire on the skin anterior to the femoral neck to judge the anteversion. A drill hole is made and guidewire is passed using 135° zig into the femoral neck and head. The position of the guidewire is adjusted till it lies in the center of the head in AP and lateral views, is positioned in the apex of the femoral head, and is confirmed by image intensifier in both the views. The implant placement in DHS is very important to avoid complications and prevent the cutting out of implant (Figs 7.18 to 7.20). The position of this screw is critical for successful fixation, which should be in the center in AP view and center or slightly posterior in the lateral view. If the guidewire is not in the center, adjust it at this stage by going anteriorly or posteriorly while keeping AP direction intact. One may have to change the point of entry on the lateral cortex, slightly posteriorly to direct the guidewire in the proper direction.
Figs 7.18A to D: X-rays showing displaced unstable intertrochanteric fracture treated by DHS in a 68-year-old male
Figs 7.19A to C: X-rays showing displaced unstable intertrochanteric fracture treated by DHS in a 63-year-old male
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Figs 7.20A to D: X-rays showing displaced unstable comminuted intertrochanteric fracture treated by DHS and additional stabilization by antirotation screw
Once the guidewire is in proper position in AP and lateral view, push its full length so that it holds at the tip in the subchondral portion in the femoral head. Another guidewire is passed parallel to the accepted guidewire to avoid spinning of femoral head and to control rotation forces. Although one should avoid superior and anterior screw placement, Baumgartner et al. 199538 devised a safe method to measure the distance of the screw tip from the apex of the femoral head (TAD), which should be less than 20 to 25 mm (Figs 7.21A and B).
These authors recommend the optimal position of the screw to be in the center and subchondral on both AP and lateral views. After confirming the position of both the guidewires, first a 7 mm partially threaded screw is passed over the superior guidewire after drilling and tapping the tract. Tap must be used for achieving easy insertion of this derotation screw (Figs 7.20A to D). It gives good compression at the fracture and avoids spinning of the femoral head, while inserting the DHS. Once the antirotation screw is passed the tract for DHS is prepared by using triple reamer over the guidewire. Guidewires can back out while withdrawing the reamer. Always check the position under image intensifier while passing and withdrawing the triple reamer. Then carefully tap the DHS tract and measure the exact length. Use DHS which is 5 mm smaller than the measured length. Observe the smooth passage of DHS, especially tightening the last few threads and avoid spinning of the femoral head. If there is any difficulty, remove the DHS and re-drill and re-tap well into the subchondral region of the femoral head or take a smaller DHS screw if an error has occurred in measurements. To facilitate the smooth gliding of the barrel of the side plate on the DHS screw, keep the end of the DHS slots slightly angulated anteriorly and slide the barrel plate in this position over the screw, and then with the plate rotate the DHS screw and plate combine to fit on the lateral side of the bone.
Occasionally, if the barrel plate is not sitting on the femur all the way one may have to change the plate to 130° or 140°. This error occurs due to a few factors while passing the guidewire. Keep the 135° jig snugly fitting on the femur all the way. If not careful at times it does not fit on the distal part of the femur and hence the guidewire will be at a smaller angle.122
Figs 7.21A and B: Photographs showing the Baumgartner et al. method of calculating TAD, the safe method to measure the distance of the screw tip from the apex of the femoral head (TAD), which should be less than 20 mm
It is generally not desirable to change the tracts if only 130° plate can be put and not 135°. But if 125° is the only plate which can be passed, then we suggest change the angle of the screw by doing the whole procedure again, which may make the head a little hollowed. This has to be avoided all the time. We suggest, do not forcibly put 135° plate if appropriate angle is 130° as this will not allow the smooth gliding of the screw plate implant39 (Figs 7.22A and B).
If the lower end of the side plate is not touching the shaft of the femur, then it means 135° is not correct and at this stage it should be changed to 130° side plate for smooth gliding of the screw. Do not forcibly hold the 135° plate and fix the screws, since it will result in the angulations of the screw 123within the DHS assembly and hamper the smooth gliding of DHS and it will not achieve its dynamic effect during the collapse of the fracture (Figs 7.23A and B).
Figs 7.22A and B: Effect of telescoping in 135 (A) and 150 (B) degrees SHS. This force when applied splits in vertical force and force along the neck which is about 135°
A few thin short ladies in India and Asia have a neck shaft angle of 130° and will need 130° assembly. However, under no circumstances should a 125° assembly be used since it will not collapse.
It is advisable to keep the screw assembly rod inside the DHS assembly and then glide the side barrel over the rod, which will easily go inside over the screw. If assembly rod is not used, the screw will be lying along the lateral edge of the hole in the femoral shaft and will settle on the upper border of the hole where it will be difficult to introduce the barrel plate. The hole in DHS has to be kept in the center, so that the side plate can smoothly slide over the screw. If the barrel plate does not glide easily do not force or hammer since it will misshape the top of the screw and will not allow the gliding of the side plate. If the head of the DHS screw is damaged, it is desirable to change the DHS to achieve smooth gliding. It is better to check the DHS assembly on the operation trolley before it is used, especially for its gliding effect and length of screw and having two components of assembly from different companies should be avoided.
There must be enough room for the implant to collapse before the screw impinges on the barrel.3941 Lately, after observing the disengagement of 124the sliding screw from the barrel, many authors recommend leaving the top compression screw in the sliding device.
Figs 7.23A and B: (A) Impingement of hip screw in barrel; (B) X-ray showing DHS fixation with no evidence of telescoping-collapse in the assembly even at the end of 10 months
The screw is inserted to lie within 1 cm of the subchondral bone. Finally the four to five-hole 135° barrel plate is inserted over the lag screw and the top screw is tightened within the plate barrel to achieve compression. The impaction of the fracture is chieved by releasing the traction and gently thumping the foot piece towards the proximal fragment. Finally four cortical screws fix the plate.
The impaction maneuver enhances the fracture stability and prevents fracture distraction. Routinely, a long barrel plate is used to maximize the screw barrel engagement and to minimize the jamming of lag screw within the barrel. However, if the screw is shorter than 75 mm, a short barrel plate 125is used, to prevent postoperative impaction that exceeds the capacity of the device.40,41 The minimum amount of available screw barrel slide necessary to reduce the risk of implant failure has been estimated to be 10 mm, whereas in the fractures stabilized with less than 10 mm of available slide, the risk of implant failure was more than three times greater than in fractures with at least 10 mm available slide.41 The DHS allows controlled impaction of the fracture by telescoping of the lag screw in the barrel plate. However, this impaction allows only uniaxial dynamization. Whereas if Medoff plate is used it allows impaction in barrel plate as well as parallel to the longitudinal axis of the femur.18,19 In Medoff's plate sliding occurs along both the femoral neck and the femoral shaft resulting in biaxial dynamization.19 The Medoff side plate of four or six holes is attached, inserted over the lag screw and is adjusted in such a way that plate sliding of 1 to 2 cm is available (Figs 7.24A to C).
Figs 7.24A to C: Photograph showing Medoff's plate
126
The screw holes are designed to direct the anterior and posterior plate-holding screws to converge at 30° angles. We have no experience of this plate.
 
Open Reduction of Intertrochanteric Fracture
Most of the time closed reduction is easily obtained by traction and other maneuvers. All tricks of closed reduction, like correcting sagging by pushing it up, abduction, adduction or rotation alteration should be used. When all of the above do not achieve close reduction, one should not hesitate to do an open reduction.
 
Open Reduction: Surgical Procedure
Put the patient on traction table. Let some knowledgeable person manage the foot piece. Make an incision through the vastus lateralis in the anterior one-third and posterior two-thirds so that anteriorly fracture area can be exposed. With periosteum, strip bone from the lesser trochanter area proximally and distally to expose and visualize fracture surfaces. Generally, traction does not reduce, as two-pieces are jammed in each other. Disimpact the fracture with bone hook, pulling the trochanter piece outside towards the surgeon.
Once two fragments are disimpacted, the proximal neck and calcar will be visualized (Fig. 7.25). With long instruments like the artery forceps, levers, bone hook, or Mixter artery forceps, the proximal piece is adjusted to the distal piece under vision and confirmed on C-arm after correction of sagging (Figs 7.26 and 7.27). If correction is achieved, DHS is executed. Bone to bone opposition is most important; once fracture is reduced it should be stable when traction is not given (Figs 7.28 and 7.29).
Sometimes the upper fragment is abducted and externally rotated by muscles attached, and cannot be reduced in traction and internal rotation (Figs 7.30A to F the fracture is very peculiar, X-ray is typical). It can only be reduced by externally rotating and abducting the distal fragment to match the displacement of the upper fragment. It is difficult to pass the guidewire and DHS in this abducted and fully externally rotated position of the distal fragment on the traction table. It can be handled by putting Steinmann pin in the proximal fragment and controlling it with this pin. Then adduct and internally rotate the proximal fragment with this Steinmann or Schanz pin and fix the fracture once it is reduced. The last three examples are of the same type of fracture (Figs 7.27 to 7.29). The example given below of nonunion is very typical same deformity.
If fragments are comminuted and reduction is achieved but is not stable due to crushed bone, then Diamon Hougston technique of medialization with impacting proximal beak in the distal shaft should be done (Figs 7.28 and 7.29). There are reports which say that only anatomical reduction should be done. All the reports say that the large majority of comminuted fractures will auto medialize to achieve stability.127
Fig. 7.25: Open reduction of intertrochanteric fracture
Figs 7.26A to I: (A and B) Under traction for reduction; (C and D) Guide passed in malreduced intertrochanteric fracture; (E and F) Open reduction with the help of Mixter artery forcep; (G to I) Perfect anatomical reduction with DHS
128
Figs 7.27A to F: Preoperative, under traction and open reduction aided by hook and fixed by DHS
Figs 7.28A to D: (A) Improperly stabilized intertrochanteric fracture; (B) Revised with open reduction and medialization and stabilization by DHS; (C) Good healing at the end of 6 months; (D) After removal of implant
Figs 7.29A to D: No reduction after 8 weeks, medialization done, healed
129
Figs 7.30A to F: (A) Preoperative; (B and C) Under traction on OT table. Upper fragment is externally rotated and abducted; (D and E) With Steinmann pin used as joystick, it is rotated internally and adducted and fracture reduced; (F) Fixed with DHS
We find that difficult four-part comminuted crushed porotic bone fractures do not reduce in stable position even when open reduction is done and we feel Diamon Hughston medialization osteotomy42 is an attractive option to treat such unstable intertrochanteric fractures with porotic crushed bones.
Once medialization is decided, it is executed in a specific manner. After open reduction identify two major fragments. With foot piece, distract the fracture, clear the end of fractures of all soft tissue clots and bone pieces with scoop. Do the osteotomy of the trochanter to expose two ends clearly. This is helped at time by distraction and external rotation on traction. At times execution is better performed by completely releasing traction, holding distal piece with bone-holding forceps, and rotating it to visualize the medullary cavity to clear the entrance of the proximal beak of the bone. Now re-apply the traction to achieve distraction. Holding the lower fragment with bone-holding reduction forceps, adjust the distal piece under the proximal beak of the bone. Abducting the distal fragment and traction helps this (Figs 7.31 to 7.33). At times, if the proximal bone is too thick then the calcar can be trimmed down to enter the proximal end of the distal fragment.
Trochanteric osteotomy is very helpful. Under C-arm, mark the level of osteotomy, which should place the medial beak of the proximal fragment inside the distal shaft, and will allow the beak to sink in the distal fragment. Cut obliquely towards proximal and medial direction and hold this detached trochanter with bone hook to keep away from the area. Displace the distal part under the calcar and then while holding this position reduce traction and lock these two pieces and then abduct the lower fragment and confirm on C-arm. Put guidewire in the neck at 140°, measure the length, usually a 130small-length DHS screw, about 50 to 70 mm is required, as the trochanter is absent.
Figs 7.31A and B: Example of medialization
Figs 7.32A to D: Complications occurring as a result of the forces at work on the unstable (conventionally fixed) intertrochanteric fracture. (A) Nail penetrates head into acetabulum; (B) Nail bends or breaks; (C) Nail cuts out of head and neck; (D) Screws break off and plate migrates laterally with collapse of fracture into varus
Figs 7.33A to C: (A) Preoperative medial bone is crushed; (B) Traction table cannot reduce in stable; (C) Medialized and stable fixation
131
While inserting the DHS always remain in the lower quadrant of the femoral head and put hip screw (Figs 7.34 to 7.36), after drilling and tapping. Select short-barrel side plate with five holes of 140° or 135° and put it on hip screw. Hold down the plate on the shaft and confirm in C-arm and confirm that two fracture fragments are locked. Now release the traction completely and thump on the foot piece to compress the medialized reduction. Put screws in the shaft. Avoid putting the proximal-most screw since it can block collapse after fixation. Be careful to adjust the distal piece in perfect rotation, never in internal rotation as gait is very bad in internal rotation. If you have to err, keep it in minimal external rotations and before fixing the plate, reconfirm rotation. If at the end of the operative procedure you find that rotation needs correction then disimpact the two fragments, externally rotate the distal fragment and reimpact since the correction of rotation is not possible when fragments are locked in malposition at the fracture site. Trochanter should be fixed with tension wire passed under glutei, to the first empty hole of the plate at the end of the surgery (Figs 7.31A and B). Patient should be mobilized in one or two days. Walking is allowed with full weight-bearing in three to four days, with walker and then slowly changes over to stick in two or three weeks.
 
Intramedullary Sliding Hip Screws
Intramedullary hip screws combine the principle of sliding hip screw with intramedullary nail, which is distally interlocked (Gamma nail, proximal femoral nail, Russell Taylor nail). Short nails with jig-guided distal locking nails, as well as full length nails are available. The implant placement offers a biological advantage since it is a closed procedure performed percutaneously to minimize the fracture zone insult and reduce the perioperative blood loss. There is decreased bending moment on the compression screw because shaft fixation is intramedullary.
Figs 7.34A to C: Diagrammatic picture of Dimon Hughston osteotomy technique
132
Figs 7.35A to D: Steps in primary medial displacement fixation. (A) Osteotomy of spike out shaft fragment (when present); (B) Placement of guidewire; (C) Shaft displaced over the spike of the head-and-neck segment; (D) Impaction of fracture and fixation with nail
Figs 7.36A and B: Dimon Hughston osteotomy
The intramedullary device is mechanically stronger as the lever arm shifts medially thus giving better resistance to failure.4348 The intramedullary nail acts as intramedullary buttress to prevent excessive shaft medialization (Figs 7.37A and B).
 
Mechanical Advantage Over DHS
 
Operative Procedure
It is a closed procedure usually performed on the traction table in supine position. Fracture reduction is a prerequisite for closed interlocking nailing.133
Figs 7.37A and B: X-ray showing the difference in the biomechanics by two different methods of fixation, eccentric by DHS and side plate and intramedullary hip screw, which is far superior
After acceptable reduction is achieved, the neck fracture is temporarily fixed with two guidewires, which should not come in the path of the nail. Limb needs to be adducted for passing the nail from the tip of the greater trochanter. Once fracture neck is fixed with temporary guidewires, limb is adducted to make the tip of the greater trochanter prominent. The limb is adducted temporarily even without fixing neck with K-wires if decided not to fix. It is not a must. Point of entry is taken over the tip of the greater trochanter halfway between its anterior and posterior surface. These are better confirmed by C-arm and see that in lateral view, point of entry is in line with the medullary cavity of the shaft femur. Under biplanar intensifier open the medullary cavity with awl and pass the ball-tipped guidewire. Then the proximal femur is aggressively reamed by gradual serial reaming to accommodate the intramedullary nail with a diameter of 17, 18 mm proximally and about 11 to 12 mm in the diaphysis. The proximal part should be reamed up to the desired level separately after distal reaming is done. An intramedullary nail of appropriate diameter (10–12 mm) attached to the jig is used and placed in the canal by simple manual force only. Do not hammer the nail. Depending upon the choice of reconstruction nail, subsequent operative steps differ, whether Gamma nail or PFN.
 
Gamma Nailing
Lag screw insertion into the femoral head is then done through outrigger guides like sliding hip screw. Central positioning of guidewire in the femoral head in lateral view can be achieved by elevating the jig to correct the sag of the femoral shaft and the limb should be abducted to correct the coxa vara to achieve good center position in AP view and then the guidewire should be passed in the femoral neck and head. Even if temporarily the fracture was 134fixed with two guidewires, the position of the fracture may change when adduction is done. This can be easily corrected after central nail is passed by abducting the limb and confirming the neck shaft angle, which should be reproduced, by traction and abduction if needed. And then with the proximal jig attached to the nail, the guidewire is passed in the femoral neck and head. Drill the neck and head by cannulated drill and after tap is used pass the screw in the head of the femur. Then setscrew is inserted over the top of the nail and tightened until an audible snap is heard. Subsequently, axial traction should be released and distally the nail should be interlocked through the jig (Figs 7.38 and 7.39).
There are various modifications in the implants and instrumentation for newer designs, like Russell Taylor's nail, and proximal femoral nails (PFNs) where the basic principle remains the same where fracture is fixed by closed procedure and proximally locked in the femoral neck and head and distally locked in the femoral shaft. The proximal fixation is done by two cancellous screws placed in the femoral head, 6.5 mm superiorly and 8 mm distally.
Figs 7.38A to G: Operative steps of Gamma nailing
135
Figs 7.39A to D: Unstable inter-sub-trochanteric fracture stabilized by standard Gamma nail
Whereas the distal screw is inserted after proximal screw fixation, much away from the distal tip to avoid the stress rising effect of the tip of the nail after the traction is released. The implants might be short or long depending upon the fracture configuration.
 
Proximal Femoral Nail
The standard PFN with a length of 200 mm is implanted after taking a small incision of 3 to 5 cm over the tip of the greater trochanter.49 After incision through the muscle and fascia the point of entry is taken over the tip of the greater trochanter under an image intensifier in both the planes. After making the entry by awl the medullary canal is connected by hand reamer and guidewire is passed beyond the fracture into the shaft. Proximal femur is reamed up to 17 mm by serial reaming. The PFN measuring distally 10 to 11 mm in diameter is then passed manually into the femoral shaft. Once the nail is seated fully, see the slots for the neck screws, whether they are at the level where two screws can be passed in the neck of the femur. Using C-arm control, the first guidewire for the neck screw is placed in the femoral neck so that the screw can be placed in the lower half of the neck on the anteroposterior view and centrally/or slightly posterior on the lateral view. Then the second guidewire for the antirotation hip pin is introduced.136
Figs 7.40A to F: (A) Position on traction table; (B to D) Adduction before locating tip of trochanter; (E) Insertion of nail while limb in adduction; (F) Good reduction with PFN and proximal screws while limb in abduction
The hip pin is introduced first, but no further than to a horizontal line through the center of the head. The neck screw should be introduced after antirotation hip pin (Figs 7.40A to F).
Anteversion of the neck is provided in the nail itself, but if needed the nail with the jig are externally rotated to enter in the center of the neck. This can be confirmed in C-arm. It is observed that if the proximal jig is not transparent it will block the lateral view of the neck of the femur. This can be solved by turning the C-arm from the dead lateral position to the oblique position and confirming that the screw is in the neck in all directions. The 137second proximal screw is also passed in a similar way. Sometimes the neck of the femur in smaller built people is so thin that it is difficult to pass two screws in the neck and hence only one can be passed.
To measure the influence of lag screw placement on migration, the femoral head should be divided into nine sectors by drawing two parallel lines on the anteroposterior (AP) radiograph to divide superior and inferior parts and two parallel lines on the lateral radiograph to divide anterior and posterior parts.50 The lag screw should be inserted into the femoral head as deeply as noted in the AP view, and centrally in the lateral view (Figs 7.41A to C).
The tip of the lag screw should always be inferior to the center of the femoral head. Anatomic and biomechanical studies have shown that the superomedial quadrant of the femoral head is the weakest part for the implant, and therefore proper positioning of the screw is emphasized. The optimal position—inferior on AP view and central on lateral views should be achieved.
Figs 7.41A to C: Technique for placement of lag screw in the femoral head. Femoral head is divided into 9 sectors by drawing 2 parallel lines on the (A) AP radiograph to divide superior and inferior parts and 2 parallel lines on the (B) Lateral radiograph to divide anterior and lateral parts; (C) All the lag screws are inserted in the inferior part of the femoral head
138
Depending on the type of fracture, distal static or dynamic interlock is obtained afterwards; using the same aiming device and the intramedullary nail is interlocked distally by one to two screws.
If the superior antirotation hip pin is longer than the lag screw, vertical forces would increase on the hip pin and start to induce cut-out, Z-effect will occur. This might force the hip pin to migrate into the joint and the lag screw to slide laterally. The hip pin should be at least 10 to 15 mm shorter than the lag screw. If the hip pin is shorter than the lag screw the cut-out of the femoral head and unacceptable implant or fracture displacement is not observed, and it prevents overloading of hip pin and cut-outs (Figs 7.42 to 7.44). Lateral slide may occur more often in patients with a PFN than a Gamma nail, because of impaction of the fracture, rather than migration of the screws, assuming that anchorage of the lag screws in the femoral head for PFN and that of the Gamma nail are similar.50,51 Restriction of the sliding mechanism of the Gamma nail caused by the more rigid femoral neck screw-nail assembly may initiate cut-out or penetration of the joint.
 
Complications of Intramedullary Hip Screw
Complications of implant failure are known even for this surgical fixation, especially in unstable intertrochanteric fracture. Penetration of implant and cut-outs from femoral head is also a known complication (Figs 7.45 and 7.47).
Figs 7.42A to C: Operative picture of comminuted intertrochanteric fracture treated by PFN
139
Figs 7.43A to D: (A and B) X-ray showing intertrochanteric fracture, good reduction on traction table; (C) Reduced position; (D) Fixation by PFN
Figs 7.44A to F: X-ray showing intertrochanteric fracture treated by PFN
The Z-effect and reverse Z-effect is one of the major problems, screw backing out and disturbing the reduction, is disaster (Figs 7.46A and B). When fracture is unstable it is not necessarily an ideal implant as it was thought earlier, it is as good as DHS in stable fracture. The PFN is less traumatic as it is percutaneous surgery without blood loss. In four-part displaced fracture it was thought to be superior, but that claim is not substantiated by controlled studies. Breakage of implant is also seen in Gamma nail and PFN (Figs 7.46C and B).140
Figs 7.45A and B: (A) Bent Jewett nail; (B) Penetration of Jewett nail in hip joint
Figs 7.46A to D: Complications of PFN. (A and B) Reverse Z-effect Gamma nail; (C and D) Broken Gamma nail, bent Gamma nail
Fig. 7.47: DHS—13 years later nail penetrating into joint leading to arthritis
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Review of the Literature
The literature regarding DHS, Gamma nailing and proximal femoral nailing is discussed in detail. Baumgartner et al. (1998)31 found no significant differences between intramedullary sliding hip screw and compression hip screw, even when compared in unstable fractures. Whereas Hardy et al. (1998)32 showed that sliding hip screw was associated with improved early mobility and significant decrease in limb shortening in unstable fractures. KS Leung et al.26 in 1992 published an article comparing Gamma nailing with dynamic hip screw for peritrochanteric fractures. Since a few complications occurred with the use of the standard Gamma nail the anthropometric study was performed on Asian-Chinese bones and accordingly the original Gamma nail was modified, and called Gamma AP (Asia Pacific27) for the thinner Asian population. This AP Gamma nail is 180 mm long, has a distal diameter of 11,12 mm and mediolateral angulations of 4°. Whereas the newly developed TFN nail is 160 mm long, has distal diameter of 11,12 mm and mediolateral angulation of 7°. The author concluded that the final outcome for Gamma nailing in fixing peritrochanteric fractures is similar to that of DHS, but is achieved with less surgical trauma, less screening time, less blood loss and earlier rehabilitation. With the use of modified Gamma AP nail and careful operative procedure, uniformly good results can be obtained. The procedure is easy for implantation of nail and the possibility of early weight-bearing even after complex peritrochanteric fractures can be considered.
Briddle et al.28 did not recommend Gamma nail routinely because of secondary femoral shaft fractures, which occurred perioperatively or in the immediate postoperative period secondary to poor operative procedure or stress riser at the tip of the nail. However, for difficult peritrochanteric fracture with subtrochanteric extension or reverse oblique fracture where other forms of fixation are less satisfactory, the Gamma nail may be useful.
Haldar25 promoted the Gamma nail, which achieves semiclosed fixation of peritrochanteric fractures facilitating fracture union without major changes in the proximal femoral anatomy. The stability of the fracture could be achieved without anatomical reduction of the posteromedial comminuted fragment, and distal locking provides control of rotation in unstable fractures. The nail substitutes for the incompetent posteromedial cortex and lateral cortex. In his series complications were few, the commonest being fracture around the greater trochanter which did not influence the course of the final outcome.
Radford,29 Aune,30 Baumgaertner,31 Madsen et al.20 reported a study of Gamma nailing comparing it with sliding hip screw where complications of the fracture at the tip of the nail or through the interlocking hole, including intraoperative fracture, were reported. Hardy32 concluded in his study that routine use of intramedullary screw could not be recommended for stabilization of intertrochanteric fractures. Similarly, clinical results of Gamma nailing with a few complications for the use of Gamma nailing were published,4348 where routine use of this technique for intertrochanteric fixation was not encouraged.142
Parker M and Handoll H,48 with Cochrane database study in October 2005, after analyzing 32 clinical trials, studied 3646 patients in 20 trials compared the treatment of trochanteric fractures by Gamma nailing and sliding hip screws, and comparison of IMHS and SHS. The Gamma nail was associated with an increased risk of operative and later fracture of the femur and an increased reoperation rate. There were no major differences between implants in the wound infection, mortality or medical complications. Five trials, involving 623 people, compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group: all cases of operative and later fracture of the femur occurred in this group. Results for postoperative complications, mortality and functional outcomes were similar in the two groups. Given the lower complication rate of the SHS in comparison with intramedullary nails, SHS appears superior for trochanteric fractures.
The AO group in 1996 designed a new intramedullary device—proximal femoral nail (PFN)—to be implanted by minimal invasive technique for the treatment of proximal femoral fractures.49 The PFN system has some major biomechanical innovations to overcome the limitations of Gamma nailing:4951
  1. The addition of the 6.5 mm antirotation hip pin to reduce the incidence of implant cut-out and the rotation of the cervicocephalic fragment.
  2. The smaller diameter and fluting of the tip of the nail, specially designed to reduce stress forces below the implant and, therefore, the incidence of low-energy fracture at the tip.
  3. The greater implant length, smaller valgus angle and setting of this angle at a higher level (11 cm from the proximal end).
  4. The more proximal positioning of the distal locking, to avoid abrupt changes in stiffness of the construct. In this assembly, the neck screw is placed closer to the calcar, taking into account the need to place the antirotation hip pin in the superior part of the neck.
The PFN also had complications, Z-effect and reverse Z-effect of about 10 to 21 percent. Werner et al. were the first to introduce the term Z-effect, detected in five (7.1%) of 70 cases Goldin et al49. The incidence of cut-out of the neck screw in this study was 8.6 percent. The Z-effect phenomenon has been described as a characteristic sliding of the proximal screws to opposite directions during the postoperative weight-bearing period; normally, a vertical force passing from the center of the femoral head tends to move the affected hip into varus as soon as the patient is mobilized. This leads to normal sliding of both proximal screws achieving the expected compression at the fracture site. In some cases this sliding occurs only in case of one of the proximal screws while the other remains in its initial position leading to penetration of the femoral head. An analysis of these Z-effect cases showed that all these patients had unstable trochanteric fractures with comminution of the medial cortex. The reverse Z-effect described by Boldin et al.49 occurred with movement of the hip pin towards the lateral side, which required early removal. The mechanism is similar, but here the hip pin is 143sliding back, whereas the neck screw remains impacted to the hole of the nail. In their prospective study of 55 patients with unstable intertrochanteric or subtrochanteric fractures followed-up for 15 months on an average, they had three cases with Z-effect and two with reverse Z-effect. This Z-effect with migration of the hip pin into the joint can be avoided by using a ring on the lateral side of the hip pin. The most recent study evaluating the use of PFN is from Fogagnolo et al.52 who reported 46 patients with an average rate of intraoperative technical or mechanical complications of 23.4 percent. They also reported “lateral protrusion” of the screws in 21.2 percent of the patients, whereas 10.6 percent of them had “intra-articular migration” of the neck screws (reverse Z-effect?). They also reported two implant failures and one fracture below the tip of the nail, whereas only 30 percent of their patients recovered the previous level of functional scores. A possible explanation for the Z-effect phenomenon is the impaction of the hip pin into the proximal hole of the nail while the neck screw is normally sliding back during the weight-bearing period. The proximal fragment and the femoral head are moved back normally, whereas the impacted hip pin protrudes through the head. Analyzing the cases of “lateral or intra-articular protrusion” of the cephalic screws, they suggested as a possible explanation—the screws were jammed or their sliding through the PFN did not proportionally follow the fracture subsidence or impaction and, therefore, the PFN implant acted almost as a fixed device.
Summarizing all these phenomena of Z-effect, reverse Z-effect and lateral or intra-articular sliding of cephalic screws, it might be inferred that the PFN has a decreased sliding potential due to the absence of a barrel coupled to the proximal screws. The addition of such a barrel might permit the use of shorter screws and improve the sliding potential of the implant reducing the risk of those complications.
The currently used Gamma nail as an intramedullary device has a high learning curve with technical and mechanical failure rates of about 10 percent (collapse of the fracture area, cut-out of the implant, fracture of the femur shaft).53,54 AO, therefore, developed the PFN with an antirotational hip pin together with a smaller distal shaft diameter to avoid these failures. In an experimental study, Götze et al.55 in 1998 compared the loadability of osteosynthesis of unstable peritrochanteric and subtrochanteric fractures and found that the PFN could bear the highest loads of all devices. Simmermacher et al.56 in 1999, in a multicenter clinical study, reported technical failures of the PFN after poor reduction, malrotation or wrong choice of screws in 5 percent of the cases in a study of 191 cases (of which 170 were unstable) and no cases of mechanical complications such as fracture below the tip or bending-breakage of the implant. A cut-out of the neck screw occurred in 0.6 percent. Domingo et al.57 in 2001, prospectively evaluated 295 patients in whom the majority (59%) had a 31-A2 intertrochanteric fracture and reported technical complications in 12 percent of the patients during the operation, 27 144percent in the immediate postoperative period and late complications in 4 percent. Banan et al.58 in 2002, reported a higher technical failure rate (8.7%) due to cut-out, one case of implant failure and two cases of fracture below the tip of the nail after a second fall, out of 60 patients with exclusively unstable trochanteric fractures. Al-Yassari et al.59 in 2002, reported an 8 percent incidence of cut-out and one case of fracture around the tip of the nail after a second fall, in a total of 76 patients. Among the four cases of screw cut-out, there was one of protrusion of the antirotational hip pin (Z-effect?). A study by Christian Boldin et al.49 showed a higher rate of complications, perhaps because 34/55 of the proximal femoral fractures were 31-A3 fractures. They achieved postoperative anatomical fracture reduction in only 34/55 patients, and immediate full weight-bearing was allowed in nine-tenths of them. A cut-out of the neck screws was seen in two patients because the neck screws used were too short. In the literature, cut-out frequencies in proximal femoral fractures have been reported in up to 10 percent. An intraoperative fracture displacement during manual introduction of the nail into the femoral shaft has not been reported with the Gamma nail2528,20, 53, 54 but this has been a problem with the PFN. One reason may be that the entry point of the PFN at the tip of the greater trochanter is located directly in the fracture region of 31-A2 fractures, which can cause an intraoperative fracture displacement. However, Simmermacher et al.56 had no cases of intraoperative fracture displacement using the PFN mainly in 31-A2 fractures. In comparison to the Gamma nail, a study by Boldin et al.49 did not find any fracture of the femoral shaft and no break in the implant in PFN group.2529,20,54
There is no advantage to an intramedullary nail versus a sliding compression hip screw for low-energy pertrochanteric fractures AO/OTA 31-A1 and A2, specifically with its increased cost and lack of evidence to show decreased complications or improved patient outcome.60 There were no significant differences in the use of either nail in terms of the recovery of previous functional capacity, nor in terms of the time required for fracture healing (12 weeks on an average). With regard to the more significant technical complications recorded, shaft fractures and the cutting-out phenomenon were more common with the use of the Gamma nail, while secondary varus occurred at a greater rate when using the PFN.61 A study by Pajarinen et al.62 compared walking ability before fracture, intraoperative variables and return to the residence for DHS and PFN. Patients treated with PFN (n = 42) regained their preoperative walking ability significantly (p = 0.04) more often by the four month review than those treated with the DHS (n = 41). Perioperative or immediate postoperative measures of outcome did not differ between the groups, with the exception of operation time. The DHS allowed a significantly greater compression of the fracture during the four month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Their results suggest that the 145use of PFN may allow a faster postoperative restoration of walking ability when compared with DHS.
Proximal femoral nail (PFN) is a good minimally invasive implant for unstable proximal femoral fractures when closed reduction is possible. The modification of the PFN and careful surgical technique should reduce the high complication rate. Biomechanically, compared to a laterally fixed side-plate, an intramedullary device (the Gamma nail, PFN) decreases the bending force of the hip joint on implants by 25 to 30 percent. This has advantages especially in the elderly patients, in whom the primary treatment goal is immediate full-weight-bearing mobilization. The Gamma nail fixation is recommended for pertrochanteric fractures, but serious complications, such as cut-out of lag screws have been reported in 8 to 10 percent of cases. The number of reoperations due to technical or mechanical failures was quite high as was the incidence of intraoperative difficulties in PFN implantation. Many authors believe that variables such as the duration of hospitalization, commencement of the sitting posture, and early weight-bearing in unstable fractures are related to the pathology associated with advanced age, general health status and type of fracture rather than to the surgical technique itself. Presently it is considered that PFN is an acceptable minimally invasive implant for unstable proximal femoral fractures. Future modification of the implant to avoid the Z-effect phenomenon, careful surgical technique and selection of the patients will reduce the high complication rate.
 
Use of Bone Grafts, Bone Substitute
Plenty of bone grafts, cancellous or corticocancellous bone is used, especially in unstable comminuted fractures to enhance and stimulate bone healing. Autografts with plenty of cancellous bone represent a good choice to stimulate bone formation.
Bone substitutes, BMP can also be used in comminuted fractures. Fresh frozen bone grafts are less immunogenic, but preserve BMP, which promotes osteoinduction. Synthetic bone grafts composed of calcium, silicon or aluminum can also be considered in selected cases. Silicon base grafts incorporate in the form of Silicate (Silicon dioxide) as bioactive glasses or glass-ionomer cement. Calcium phosphate and carbonate-based grafts are capable of osteoconduction and osteointegration. Many grafts are prepared as ceramics like tricalcium phosphate, and hydroxyapatite. Alumina ceramics bond to bone in response to stress and strain between the implant and bone.
 
Augmentation with Bone Cement
In the elderly with severe osteoporosis the use of cement augmentation of proximal fixation is recommended. If the lag screw does not have purchase within the femoral head, the screw should be removed, polymethyl methacrylate cement injected into the femoral head and the screw 146reintroduced.6366 Similarly, in patients with severe osteoporosis side-plate fixation by cortical screw can be improved by augmenting with bone cement. It is used to grout and load the distribution for implant, acrylic bone cement (PMMA) functions by mechanically interlocking with bone. The PMMA cement never gained wide acceptance because of exothermic reaction, inability of remodeling, and risk of inhibition of fracture healing due to release of monomers, fibrous sheathing and poor bondage with adjoining bone. Newer bone cement–calcium phosphate (Norian SRS) and glass ionometric cement is biodegradable cement. New glass ionometric cement was first used for dental filling; it has no disadvantages of PMMA.
Aim of cement is:
  1. To create the mantle around the screw thread of implant to enhance the holding capacity (Figs 7.48 and 7.49).
  2. To fill the fracture void, especially prosthesis in the femoral head or around the femoral calcar and medioposterior defect in the trochanteric fracture.
Figs 7.48A to D: X-rays showing unstable intertrochanteric fracture treated by DHS and augmentation of fixation by use of PMMA—bone cement
Figs 7.49A and B: (A) Expandable dome plunger and lag screw to facilitate cement intrusion in the femoral head; (B) X-ray showing cement intrusion
147
Figs 7.50A to D: X-rays showing unstable intertrochanteric fracture in an 85-year-old elderly moribund patient seen in photograph, treated and stabilization by external fixator showing satisfactory union at 6 weeks
The goal of augmenting was not to fully prevent sliding, but to avoid excessive sliding to prevent fracture displacement and varus angulation.63, 64
 
Role of External Fixator
In very exceptional circumstances when the patient is very elderly, who is moribund with multiple medical problems, especially when the anesthetist refuses to administer even regional anesthesia one may consider fixation of this fracture by external fixator under local anesthesia or sedation. This procedure quickly stabilizes the fracture and gives relief so that the patient can sit by the side of the bed and can be mobilized out of bed also (Figs 7.50A to D).6769
Anil Dhal et al.67 published their series in 1991 with good results of external fixation in a selected group of patients. Moroni68,69 has published excellent results with the use of hydroxycoated pins with external fixator for the treatment of intertrochanteric fractures.
 
Prosthetic Replacement
Prosthetic replacement in fresh intertrochanteric fracture is not routinely done. Recommendations for acute prosthetic replacement currently are 148limited to unstable fractures in patients with rheumatoid arthritis, or pathologic fractures and unstable comminuted (four-part fracture) fractures. Cemented hemiarthroplasties and bipolar replacement are considered for unstable four-part intertrochanteric fractures (Figs 7.51 to 7.53).70
Figs 7.51A to C: X-rays showing comminuted unstable intertrochanteric fracture in a 65-year-old elderly lady treated by primary cemented bipolar prosthesis
Figs 7.52A to C: Unstable intertrochanteric fracture treated by primary total hip replacement
149
Figs 7.53A to D: X-rays showing unstable comminuted intertrochanteric fracture treated by primary bipolar hip replacement
Figs 7.54A to F: X-rays showing failed DHS, implant cut-out for intertrochanteric fracture treated by revision surgery and replacement by cemented bipolar prosthesis
Haentejens et al.71,72 (1989) compared the results of primary bipolar replacement and blade plate fixation, and Chan and Gill (2000)73 reported a few complications after cemented hemiarthroplasties. Unstable intertrochanteric fractures, especially badly comminuted ones are common situations wherein fracture goes into nonunion along with a lot of morbidity and at times mortality. For the salvage of failed intertrochanteric hip fractures Haidukewych et al. recommended hip arthroplasty.74 To overcome such a situation and to prevent morbidity presently these patients are infrequently subjected to primary total hip joint replacement. This has two advantages: it reduces the chance of nonunion and avoids morbidity and repeated surgeries (Figs 7.54A to F).
In a few patients of intertrochanteric fractures with failed implants which are frequently associated with poor bone quality, a damaged femoral head due to implant, damaged articular cartilage, or limb-shortening, can be salvaged 150by replacement arthroplasty, with excision of the ununited head-and-neck fragment. However, cemented bipolar replacement arthroplasty or total hip replacement is a good salvage operation for nonunion and failed sliding hip screw (Figs 7.54A to F).7074 There are a number of specific technical hurdles to successful hip arthroplasty in this setting, including the presence of failed internal fixation devices, bone deformity, bone loss, and poor bone quality. Hip arthroplasty dramatically alleviates pain and improves the function in the majority of these patients. The operation allowed most patients to regain function that otherwise had been lost, which is the hallmark of an effective salvage procedure.
 
Prosthetic Replacement of Fresh Intertrochanteric Fracture: Surgical Procedure
Keep the patient in a lateral position with anterior and posterior support to the pelvis like normal total hip position. Take a lateral approach incision like any standard hip incision.
Cut fascia lata; start from the lower border, after finding the middle of the femur shaft. Make a cut on the middle of the femur level and open up the fascia lata till the musculotendinous junction. Split the fascia lata muscle with the fingers from 8 to 10 cm proximally and now glutei will be seen underneath. Apply Charley's initial retractor under the fascia lata keeping cross bar of the retractor towards the leg side to allow easy access to the shaft femur later.
Now the approach differs from the standard anterior and posterior approach.
Identify the gluteus medius and trace to trochanter. Through the fascia over the trochanter, feel for the break in the bone of the trochanter. Open up the fascia and confirm the break of the bone of the trochanter with artery forceps or any small instrument, trace the fracture up and down, and open up this fracture fully (Figs 7.55A and B).
Figs 7.55A and B: (A) Break in trochanter; (B) Fracture opened and hip joint explored
151
Figs 7.56A and B: (A) Open split trochanter; (B) End-on view of neck shown by white arrow
There are two patterns of fractures which are observed:
  1. The trochanter is split in the lateral direction right up to the lesser trochanter, thus creating anterior and posterior flaps of the trochanter, and the lesser trochanter as a third piece, and head and neck with a part of the calcar as a fourth piece.
  2. A large piece of the trochanter along with the glutei is pulled up with small fragments and the trochanter is split up to the lesser trochanter base, with the lesser trochanter separated (Figs 7.56A and B).
Always there will be fracture gap in fresh fracture. However, the situation is different in nonunion, which needs conversion to total hip replacement (THR), and will be described later.
Open up the trochanter split and separate anterior and posterior to create a space in between. Once the trochanter is separated and bone fragments are retracted anteriorly and posteriorly, immediately underneath, end-on view will expose the calcar that is attached to the head fragment. There will be only cancellous bone of neck, seen end-on, and spherical white head will not be seen. One has to get used to this pattern, unlike the standard hip approach where the white round head is seen earlier. With artery one can move this piece and confirm that it is the part of the head and neck one is dealing with. Introduce a cork screw head removal instrument in this calcar in the direction of the head. Generally, it does not always go into the ball of the head direction and it can go on either side of the head. With the handle move the head to confirm and then cut the capsule, which is present all around the bone (Figs 7.57A to C). Move the head with cork handle and cut capsule 360° all around. As more and more capsule is cut, more and more shining femoral head will be visible. Go on cutting the capsule and see more and more head. At one stage now, when the head is visible, adjust the corkscrew in the center of the head, which will also improve the control of the head and movements of the head. Once the capsule is cut all over, the head will start coming out of the acetabulum socket. Cut the ligament teres or any other soft tissue connections if present.152
Figs 7.57A to C: (A) Cork screw head removal in the head; (B) Capsule removed and more of the head white shining is visible shown by arrow; (C) Removed femoral head
Fig. 7.58: How to judge anteversion while the limb is flexed at knee at 90° to the vertical positioned tibia and slightly more anteriorly 10-15°
At times, early in the procedure if the long calcar beak is seen, it will not allow rotation and easy access to the capsule. Trim out this beak and make it smaller, so that it does not obstruct access to the capsule or rotation.
Once the head is out, visualize the shaft of the femur in end-on view. Palpate the distal part of the shaft and see the direction. Now rotate the lower extremity and keep the knee at 90° and foot vertical (Fig. 7.58). This will give the position of the neck of the femur. Most of the time, the hip is going to 153be reduced after replacement from the posterior side, by externally rotating the lower limb. Keep the lower limb at 90° knee and ankle, and introduce the medullary canal finder and ascertain the direction of the femur. Now introduce the reamer and then broach like THR surgery till the appropriate size of the broach is introduced.
First we confirm that the anteversion of the head is perfect, which is 90° to the axis of tibia is 0° and then rotate head by 10 to 15° for anteversion. There are no landmarks on the neck of the femur and hence the only landmark is the axis of the tibia. Now is the most important step of trial reduction. When the broach is introduced deep in the femoral canal till, the tip of the trochanter should lie at the level of the center of the head in correct rotation, if the trochanter tip is in continuity with the shaft. Now introduce the trial segment and again see the level of the head, and reduce by traction, bringing prosthesis at the uppermost end of acetabulum. Holding the prosthesis in bone, with the hook to position on the uppermost part of the acetabulum is important. Now with traction and pusher introduce the head in the acetabulum.
Now are the crucial steps, move the hip in all directions, flexion, and internal and external rotation to see any impeachment. Keep the affected hip parallel to the normal leg and see the patella and see the limb length and observe the difference if any, which can be changed by neck size, or withdrawing or pushing the prosthesis in the femur. Once satisfied with all checks, dislocate the head by pulling on with the hook around the neck and traction and internal rotation. The hook is the main force. Now mark on the bone points at which the prosthesis has to position while final sitting. Mark these points, measure the distance from the fixed bony point up to which the prosthesis has to sink, and mainly 10 to 15° anteversion. Do not increase anteversion, it is very crucial to avoid dislocation. Increased anteversion will cause dislocation due to impeachment in extension and external rotation. If in doubt neutral version is better than increased anteversion.
Now prepare the femur canal, put the distal cement restrictor and dry the canal with H2O2 first and dry pack later and pass steel wires from the lateral and medial part of the femur for future suturing of the greater trochanter. Identify the lesser trochanter and pass steel wire on the lesser trochanter, on the psoas and the bone junction or make hole in the thickened part of the lesser trochanter and pass wires in it. Once ready identify these wires with separate holders, clean the area and push cement when ready with syringe and introduce the prosthesis exactly as planned, just enough distally and taking care of proper anteversion, no excessive ante or retroversion and stabilize it till cement cures (Figs 7.59A and B). Remove excess cement from the raw surface of the bone for the trochanter to sit in the gap. Larger amount of the upper end of the prosthesis will be seen in the final seating of the prosthesis as the neck is missing. Keep area clear for trochanter placement and keep bone ends clean for healing.154
Figs 7.59A and B: (A) Proper anterior version; (B) After closure
In Pattern 1 of trochanteric, split–suture the major part of the trochanter. One piece of the trochanter is with the shaft, which is the piece on which the other piece has to reduce while tightening the suture. Presently, instead of using steel wires it is advisable to use ethibond as steel wires break after 6 to 12 months and broken ends seen on X-ray gives unpleasant situation and anxiety to the patient and surgeon. With bone-cutting needle, two to three sutures are taken on the trochanter and the two major pieces are sutured. Stitches which were kept earlier before cementing from intact distal bone is used to reinforce the suturing of trochanter. The lesser trochanter is also repositioned on its original site and the closure is now completed. Postoperation, once the drains are removed, the patient can be mobilized with weight-bearing in one or two days with walker.
Generally, the patient is self-sufficient with help in one week's time.
 
In Summary
  • If there is intertrochanteric fracture with basal element, and with four-part fractures in individuals aged 80 years and above, replacement is the better choice of surgery.
  • Above the age of 80, four-part comminuted displaced fracture with osteoporosis should be replaced (not the two and three-part minimally displaced fracture).
  • Open up the trochanter fracture properly while exposing the hip for replacement.
  • End view of the neck and head should be properly exposed.
  • Entire hip capsule is cut and excised for head extraction.
  • Proper anteversion or neutral version in relation to the long axis of the tibia is maintained while implanting the prosthesis.
  • Exact limb length should be adjusted.
  • Keep bone ends free of cement for healing.
  • Trochanter should be reconstructed as anatomical as possible.
  • Immediate mobilization and rehabilitation of the patient should be done.
155
 
Postoperative Regimen and Care
Intraoperative antibiotic therapy should be continued for 24 to 48 hours after surgical fixation. Deep vein thrombosis is a concern in every elderly person with hip fractures, and although there is a debate as to what the best regimen might be, perioperative, chemoprophylaxis should be instituted in all hip fracture patients. A primary goal of treatment in any elderly patient of hip fractures is immediate mobilization. It appears to be of no benefit to order restriction of weight-bearing in lucid patients. Patient should be allowed to bear the weight as tolerated. Every patient must be evaluated for underlying osteoporosis.
 
Functional Outcome
Functional outcome for elderly patients with unstable intertrochanteric fractures is difficult to assess and depends on many factors in addition to fracture care. Successful fracture care does not always correlate with a successful outcome. Only about 50 percent of patients can be expected to regain their pre-injury function; the other half becomes more dependent in some manner.
 
Medical Complications
Medical complications after surgical fixation of unstable intertrochanteric fractures are frequent; myocardial infarction, pneumonia and urinary tract infection are the most common. Pulmonary embolism and uremia are also infrequently seen in the immediate postoperative period. The reported mortality rates for the first postoperative year are around 20 to 30 percent.
 
Mechanical Complications
 
Loss of Proximal Fixation
Following are the frequent causes of failure of sliding hip screw:
  1. Cutting out of the compression screw from the femoral head
  2. Pulling off of the side-plate from the femoral shaft
  3. Disengagement of sliding hip screw from the barrel
  4. Failure of the hip screw.
Migration of the compression hip screw with cut-out from the femoral head remains the most common mechanical complication after surgical fixation.20,3135,38,4046
A review of severe unstable fractures revealed a 56 percent failure rate of cut-out and nonunion. This needs revision of fixation, abduction osteotomy and fixation or prosthetic replacement (Figs 7.60A to D).66,7075 Most of the time cut-out is basically because of ongoing nonunion of the fracture.156
Figs 7.60A to D: X-rays showing nonunion of intertrochanteric fracture and implant breakage after stabilization by DHS, and fixation was improved by medial displacement and fixation by DHS in a 55-year-old male
 
Femoral Shaft Fractures
As a complication of unstable intertrochanteric fracture fixation, femoral shaft fracture is almost completely related to short intramedullary fixation. Femoral shaft fracture can occur at the time of implantation or postoperatively.26,2830,20,4046 Almost all the fractures occurred with standard Gamma nails which were short, had large diameters and 10° of valgus offset, which created stress riser at the tip of the nail. The Gamma nail has been redesigned and newer devices like PFN, Russell Taylor nail have been designed with less valgus curvature. Femoral fractures were associated with larger diameter intramedullary nails and aggressive surgical insertion.
 
Nonunion
Most reports of nonunion are associated with instability or loss of reduction.41 This situation can be managed by revision of fixation and bone grafting or abduction osteotomy and fixation or by prosthetic replacement (Figs 7.61A to F).74,75
 
Revision of Osteosynthesis for Nonunion of Intertrochanteric Fractures
Osteosynthesis can be done when the head and neck fragment has a large trochanter bone (Figs 7.61A to D). Basic cervical element of four-part nonunion is better treated with replacement. The basic principle is, if the implant has cut through the head, lower position of the neck should be chosen for reinserting the DHS screw, and the gap created due to the cut-through bone should be treated with bone grafts and preferably 135 to 140° barrel plate must be used (Figs 7.62 and 7.63). Medial border contact plus graft is most important. PMMA or calcium phosphate cement may be used to fix the screw of the DHS in the head. Proximal femoral nailing interlocking by PFN in pure intertrochanteric nonunion is not a good choice of implant.157
Figs 7.61A to F: X-rays showing (A) Nonunion of intertrochanteric fracture after conservative treatment; (B) Stabilized and treated by DHS in a 55-year-old male; (C) Achieved good union in 6 months
Figs 7.62A to C: (A) Preoperative; (B) Failed fixation with nonunion; (C) Same tract 140° implant and grafting united
 
Bipolar or THR after Nonunion of Intertrochanteric Fracture Femur
This is a totally different operation from primary replacement in intertrochanteric fractures. Here the trochanter is healed in malposition, mainly in external rotation. Even if it is not healed it is in malposition, mainly external rotation, hence the trochanter fracture opening approach is not feasible (Fig. 7.64).
 
Surgery
After exposure of the fascia lata, visualize the trochanter. Incision for DHS is generally anterior lateral. Hip replacement needs posterior lateral approach.158
Figs 7.63A to G: (A to C) Immediate postoperative; (D) Implant displaced after collapse; (E) After removing implant; (F) Superior empty space filled with graft, arrow and guidewire in lower quadrant; (G) Final 6 months after healing automedialis
Fig. 7.64: Nonunion with classic deformity
If three to four-finger breadth space is available, fresh normal incision is taken. If such space is not available, old incision is incorporated in new incision, connecting old with extension incision at 90° to original incision (Fig. 7.65).
When the trochanter is healed in external rotation, it overlaps the gemelii and piriformis. So for the posterior approach, all structures which need to be cut, like the gemelii and piriformis, are all not visible till the bone on the posterior part is trimmed up to the edge. It is difficult to internally rotate the hip for visibility. The sciatic nerve is vulnerable while dissecting. Hence, in this situation the anterior part of the joint should be well-visualized and Harding's anterior approach is easier than the posterior approach.159
Fig. 7.65: Clinical photograph of hip showing how the incision is extended from the old scar for THR in nonunion of intertrochanteric fracture
It is still possible to perform surgery by the posterior approach if it is the one you are used to. It is suggested to trace the sciatic nerve, separate and identify the nerve with small feeding tube or catheter around and then proceed. If it is difficult to internally rotate the limb, it is strongly suggested to change over to anterior Harding's approach. As dissection proceeds and soft tissue is cut, more and more external rotations of the limb are possible. It might require wide capsular excision of the anterior and posterior part for improving the visibility. When enough visibility is obtained, the shaft is visualized in the straight direction. After removal of the head segment, elevate the remaining trochanter and shaft with trochanter elevator or big retractor and confirm that the shaft is straight ahead. After shaft preparation, broach is positioned 10° anteversion, judged by the long axis of the tibia when it is vertical from the table. Remember, the head is going to be reduced in internal rotation and so the head will be situated anteriorly in a correct plane.
In this surgery as the trochanter has healed up often, it does not require fixation like in primary case. Mark the level of prosthesis, insert and introduce the cemented or uncemented prosthesis (Figs 7.66 to 7.68). If the trochanter is in nonunion, it will need fixation with ethibond or steel wire as discussed earlier.
This is an extremely rewarding surgery.
 
Pearls
  1. While using the posterior approach trim the posterior part of the trochanter, trace and protect the sciatic nerve and then proceed.
  2. Change over to the anterior approach if internal rotation of the limb is very difficult.
  3. The axis of tibia is lying vertical to the table, which is the only landmark to judge for the position of the prosthesis.160
Figs 7.66A to F: X-rays showing intertrochanteric fracture treated by DHS and derotation screw went into nonunion and now treated by cemented bipolar
Figs 7.67A to G: X-rays showing intertrochanteric fracture treated by DHS and derotation screw went into nonunion and implant cut-out, now treated by total hip arthroplasty
161
Figs 7.68A to C: (A) Immediate postoperative; (B) Four months later; (C) Salvage with calcar replacement prosthesis
  1. Avoid increased anteversion.
  2. Trochanter generally does not need repair.
  3. Remember, the head is seen anterior and is going to be reduced in internal rotation if anterior Harding's approach is taken.
  4. If the trochanter is in nonunion, separate it first, then normal posterior approach is possible, keep separated trochanter away by retractor and do THR and then repair trochanter with wire sutures.
 
Few Odd Observations in Intertrochanteric Fracture Fixation
 
Painful Hardware
Painful hardware after open reduction and internal fixation is probably under-reported in studies of hip fractures. The pain is often thought to result from backed out compression screw irritating femoral musculature, but nonunion must be excluded as a cause of residual pain. One might be required removal of compression hip screw postoperatively in these patients where excessive collapse has occurred and fracture has united with screw now hurting on the lateral side (Figs 7.69 to 7.71).
 
Osteonecrosis
Osteonecrosis of the femoral head is rare following intertrochanteric fractures (Figs 7.72 and 7.73).76,77 No association has been established about the type and location of implant into the femoral head. Various isolated reports have documented the unusual complication relating to separation of lag screw and side-plate, migration of the lag screw into the pelvis.78
The treatment for the osteonecrosis differs, depending upon the portion of the femoral head involved. In addition to rest and exercises, surgical 162treatment is often required.
Figs 7.69A to C: Intertrochanter-subtrochanter fracture treated by SP pin plate, 18 years later implant removed because of secondary OA hip
Figs 7.70A to C: A few odd fixations for intertrochanteric fractures
If collapse has occurred or arthritic changes are seen the best option is total hip joint replacement.
 
Subcapital Fracture Neck Femur
Subcapital fracture neck femur is a rare complication following fixation of intertrochanteric fracture femur by DHS or PFN. This is seen when there is technical error of not following the principles of TAD and TAD distance is more than 20 mm, but osteoporosis appeared to be a more significant cause than any technical error79(Figs 7.74A and B).
 
Summary and Conclusion
The most common means of surgical fixation of intertrochanteric fractures is reduction and fixation with compression hip screw and side-plate, which has stood the test of time. If the principles of TAD are followed properly, the 163chances of failure after sliding hip screws can be reduced or minimized.
Figs 7.71A to G: A few odd fixations for intertrochanteric fractures
Figs 7.72A to C: Immediate preoperative and 10 years later, avascular necrosis in intertrochanteric fracture
Other options are compression hip screw augmented with trochanteric stabilizing plate and intramedullary sliding hip screws.
The choice of surgical fixation depends mainly on the whether fracture is stable or unstable. The stable fracture may be fixed with any implants, but 164skill lies in fixation of the unstable fracture.
Figs 7.73A to D: (A and B) Immediate preoperative and 10 years later, avascular necrosis in intertrochanteric fracture; (C and D) Head split postoperative 3 years original? acquired? Immediate postoperative 24 years later AVN
Figs 7.74A and B: (A) X-ray hip showing intertrochanteric fracture stabilized by DHS with TAD distance more than 20 mm; (B) X-ray showing subcapital fracture neck femur at the tip of the threads of the hip screw
However, in a few selected cases prosthetic replacement and total hip joint replacement may be considered. Rarely, in severely moribund patients where the anesthetist refuses to administer regional anesthesia, one may consider stabilization of fracture by external fixator under local anesthesia.
 
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Subtrochanteric Fractureschapter 8

Subtrochanteric fractures occur between the lesser trochanter and a point 5 cm distally and are seen as independent entities or as an extension of intertrochanteric fractures. They account for approximately 5 to 34 percent of all hip fractures. The results of the management of subtrochanteric fractures are still uncertain. The common problem for these fractures has been malunion, delayed union or nonunion. Shortening, angular deformity and rotational malalignment were common complications after this injury. The reason is, the area fractured is mainly a cortical bone and often the fracture is comminuted. Another factor responsible is large biomechanical stresses are acting on the subtrochanteric region, which result in failure of implant fixation before bony union occurs. Although newer modalities of implant fixation have improved the care for these unstable injuries, there still occurs a high rate of implant failure, 8 to 25 percent as reported by Lindskog and Baumgartner, 2004.1
The clinical picture of subtrochanteric fractures resembles the fracture shaft femur or trochanteric fractures. Since substantial2 forces are required to produce this injury, associated injury of the same extremity or elsewhere should always be looked for. There are many muscle attachments in the proximal femur, because of which certain characteristic deformities are seen in subtrochanteric fractures (Fig. 8.1). The proximal fragment usually is flexed, abducted and externally rotated because of the pull of the iliopsoas, glutei and short external rotators. The distal fragment is adducted and shortened because of the pull of the adductors and hamstrings. Two different groups of patients are commonly observed in subtrochanteric fractures. Either it is seen in old patients following trivial trauma because of osteopenia which results in minimal comminution, oblique or spiral with a wide medullary canal and thin cortices (Low subtrochanteric) Type II or it is seen following high-energy trauma in young individuals with normal tone of muscles and good quality of bone with severe comminution and significant damage to soft tissues (High subtrochanteric) Type I.170
Fig. 8.1: Location of subtrochanteric fracture according to intensity of injury
 
Classifications
Several classifications of subtrochanteric fractures have been suggested. In some of the classifications, the subtrochanteric fractures were included in the classification of trochanteric fractures (Boyd and Griffin,3 1949). There are various classifications:
  1. Fielding and Magliato4 (1966), depending upon the site of the fracture in the subtrochanteric area (Fig. 8.2A).
  2. Seinsheimer's classification5 (1978), depending upon the number of major fragments and location and shape of fragments (Fig. 8.2B).
    Figs 8.2A and B: (A) Fielding and Magliato classification; (B) Seinsheimer's classification
    171
    Figs 8.3A and B: (A) Russell Taylor's classification; (B) Waddell's classification
  3. Russell-Taylor's classification,2,7 depending upon the involvement of the piriformis fossa and the lesser trochanter in the subtrochanteric region (Fig. 8.3A).
  4. Waddell's classification6 (1979), depending upon the degree of medial comminution. The outcome of fracture treatment depends on the quality of reduction and ability to restore the medial buttress (Fig. 8.3B).
  5. AO/OTA classification: The comprehensive classification of long bones’ fracture by AO ranges from 32A1 to 32C3. The classification is based on the fracture pattern and degree of comminution (Fig. 8.4).
 
Biomechanical Factors
The subtrochanteric region has very high mechanical stresses, the medial and posteromedial cortices are subjected to very high compressive forces, whereas the lateral cortex experiences high tensile forces. Koch8 (1917) analyzed mechanical stresses on the femur during weight-bearing and found out that compression forces exceeded 1200 lbs per square inch in the medial subtrochanteric area (Frankel and Burstein 1970).9 Whereas lateral tensile stresses were 20 percent less. Rybiki, Simonen and Weis10 (1972) found out that higher forces were generated with eccentrically placed devices such as plate and screws compared to centromedullary devices like proximal femoral nail (PFN) and Gamma nail, and recon nails. Tencer et al.11 (1984) did biomechanical studies in cadaveric models. Their studies revealed that interlocking centromedullary devices had greater bending stiffness, had nearly normal femoral torsional stiffness and had very high axial load-sustaining capacity (350-400 lbs) of body weight. Schatzkar and Waddell12 (1980) have shown that compression forces, which load the medial femoral cortex, are considerably greater than the torsional strains on the lateral 172femoral cortex.
Fig. 8.4: AO/OTA classification
These large stresses on the subtrochanteric area make medial cortical restoration mandatory at the time of surgery to prevent cyclic loading and failure of any device used on the tension side of the femur. Velasco and Comfort13 (1978) reported that as little as 2 mm separation of the medial femoral cortex would lead to medial collapse and lateral plate bending and failure of implants.
 
Management
Conservative nonoperative treatment usually does not succeed and is rarely indicated, hence surgical treatment is necessary most of the time, 173though very rarely, skeletal traction through distal femur may be applied in very comminuted long fractures which are not grossly displaced. The fracture frequently extends into the diaphysial region, which has decreased vascularity and has poor healing potential. Many devices for internal fixation have been recommended because of the high rate of complications after surgical treatment. Each of these devices has advantages in certain types of subtrochanteric fractures and their selection should be based on individual fracture anatomy.
 
Surgical Procedures
Many implants have been used in the past for the stabilization of subtrochanteric femoral fractures. Between 1950 and 1960 the commonly used device was Jewett nail plate, consisting of a triflanged nail fixed to a plate at varying angle from 130 to 150°.
 
Fixed Angle Nail Plate (Jewett Nail)
Although Jewett nail achieved adequate stabilization, it did not allowed fracture impaction postoperatively or it resulted in penetration of the nail into the hip joint, or cutting of implant superiorly or the device on loading resulted in breakage of implant (Figs 8.5A to C).4,14 If fracture impaction did not occur, the loading on the device resulted in breakage of implant at nail plate junction or separation of plate or screws from the femoral shaft. The implant fell into disrepute since the overall results were disappointing.4,14,15 Once upon a time internal fixation with strong Jewett nail possibly supplemented by anterior plate and bone grafting was the best method. A very high incidence of varus deformity, acetabular penetration and implant failure led to a decrease in the routine use of the Jewett nail plate for subtrochanteric fractures (Figs 8.5A to C).
Figs 8.5A to C: X-rays showing fixations by Jewett nail with (A and B) Implant breakage; (C) Penetration into the hip joint
174
The most commonly used implants today are PFN or Gamma nail type of cephalo condylar implant and 95° blade plate or DCS.
 
95° AO Angled Blade Plate (Figs 8.6 and 8.7)
Ninety-five degree AO angled blade plate has been used for many years to stabilize subtrochanteric femoral fractures. Plate and screw fixation of subtrochanteric fractures is still advocated by many surgeons. AO 95° condylar angled blade plate gained a lot of popularity around the mid-seventies. The 95° designs allowed two to three screws to be inserted through the plate into the region of calcar, which provides additional fixation in the proximal fragment (Figs 8.6A and 8.7).
AO angled blade plate can be easily inserted even in small proximal fragment and it provides stable fixation, though technically it is a demanding procedure. Initially, a very high success rate was reported in transverse subtrochanteric fractures with the use of 95° fixed angled blade plates which achieved adequate stable osteosynthesis with high union rate.
Figs 8.6A and B: 95° blade plate and 95° DCS which is user-friendly
Figs 8.7A and B: (A) 95° angled blade plate; (B) Low subtrochanteric fracture stabilized by 95° angled blade plate and interfragmentary screw
175
Both Schatzkar and Waddell12,16 recommended the use of 95° AO blade plate in selected subtrochanteric fractures. A subtrochanteric fracture where anatomical restoration of the medial femoral cortex is possible, should be fixed by AO blade plate and if possible fixation by interfragmentary compression of medial cortical fragments should be done. The surgical technique is very challenging; the plate must be inserted precisely in all the three planes, axial, coronal and sagittal.17
Waddell4 reported failure of AO blade plate in about 20 percent of fractures (1979). In 1989 Kinast et al.18 presented a study of subtrochanteric fractures fixed by 95° AO blade plate by using new method of fracture fixation. The blade plate is introduced into the proximal fragment first and fracture is reduced indirectly using AO distractor and the plate is then fixed to the femur by screws avoiding soft tissue stripping.
Asher et al.16 reported the use of a 95° condylar plate wherein 30 percent patients had loss of fixation with poor results. The poor result was attributed to technical errors in obtaining anatomical reduction and bony contacts medially. Kinast et al. (1989) reported a very high complication rate of about 20 to 32 percent including infection and nonunion18 whereas Berman et al.19 (1979) reported 100 percent union with no implant failure but suggested that if medial buttress cannot be restored, medullary nailing may be preferable to plate fixation. Kinast et al.18 studied 47 patients of subtrochanteric fractures and used two different methods of surgical stabilization by using 95° condylar blade plate, one by direct open reduction and visualization of fracture site which involved extensive dissection and the other method was indirect reduction technique. The authors concluded that the use of an indirect technique, which preserves the vascularity of the medial fragments, and osseous compression was important criteria for favorable outcome by using 95° condylar blade plate.
 
Dynamic Condylar Screw Plate
The 95° compression screw plate has been used successfully for many years in treating subtrochanteric femoral fractures. Orthopedic surgeons are very familiar with the use of this implant because of the common use of 135° compression hip screw (DHS/SHS) in treating intertrochanteric fractures. A very important advantage of DCS over 95° condylar plates is that the construct can be adjusted in the sagittal plane after the compression screw is passed in the femoral head neck (Figs 8.6B, 8.8, 8.9, 8.11). Pai20 reported excellent results in type II subtrochanteric femoral fractures treated with 95° condylar plate and indirect reduction technique. Many authors reported good results using 95° dynamic condylar screws for the stabilization of subtrochanteric fractures. Nungu et al.21 reported A series of 15 subtrochanteric fractures treated by 95° dynamic condylar screw, whereas Pai20 reported 16 subtrochanteric fractures with greater trochanteric fracture 176extension stabilized by 95° dynamic condylar screw by using the principle of indirect reduction without bone grafting.
Figs 8.8A to D: (A) Picture of DHS and X-ray showing good stabilization; (B to D) Subtrochanteric fracture fixation by dynamic condylar screw, but fracture healed in varus
Figs 8.9A to D: (A) Medial cortex reconstructed and 2 screws in proximal fragment result after 18 years; (B to D) DCS medial gap filled with Ca hydroxyapatite. Fracture healed and after removal of implant
Pai18 reported union rate of 93.7 percent, whereas Kulkarni and Moran22 reported a 20 percent incidence of fixation failure in the elderly when stabilizing subtrochanteric femoral fractures with 95° compression screw-plates.
Vaidya et al.23 emphasized the principle of indirect reduction technique while condylar screw plate which maintained the biology of the fracture environment for successful outcome. They reported no nonunion and found that careful attention to preserving soft tissue attachments to bone would enable the fracture to heal without the use of bone grafts. When using DCS, the proximal fragment should preferably have two additional screws and if that is not possible, at least one screw. If one screw is also not possible then 95° condylar blade plate only should be done and the temptation of the easier surgery of DCS should be avoided. Most important is the integrity of the medial column. If this is not established by closed reduction by adjusting bone fragments and then if bone gap is present it must be filled with bone graft or bone substitute (Figs 8.10A to C).177
Figs 8.10A to C: DCS with 2 screws in the proximal fragment and medial gap filled with Calcium triphosphate
Fig. 8.11: Reconstruction of proximal fragment with DCS lag screw—fracture healed
 
Compression Hip Screw (DHS/SHS)
Around the 1970s compression hip screw (DHS) was a very popular method of fixation for subtrochanteric fractures, after its high success for the treatment of intertrochanteric fractures. Their use was intended to allow controlled collapse of intertrochanteric fractures, which may be undesirable in subtrochanteric fractures. Many workers have reported good results with no implant failure [Wile, Punjabi and Southwick (1983)24, Bergman et al. (1987)25] whereas Wadell 1979 reported 10 percent failure and nonunion.6 Berman et al.19 reported similar results—they had no incidence of implant failure in a series of 38 subtrochanteric fractures stabilized by sliding hip screw and bone graft.178
With the availability of better-designed devices for treating subtrochanteric femoral fractures, the 135° compression screw plate should not be used for the fixation of subtrochanteric fractures. Modification of sliding hip screw (SHS) by the use of Medoff sliding plate was designed to allow compression along both the axes of the femoral neck and the longitudinal axis of the femoral shaft was introduced. A distal screw can also be used to achieve additional intraoperative longitudinal compression at the fracture site. If the locking set screw is not applied within the barrel, biaxial compression can occur along the femoral neck and femoral shaft. Ceder et al. (1998)26 reported the results of 32 consecutive subtrochanteric fractures stabilized by the Medoff sliding plate and followed for one year. In 97 percent cases the fracture united where plate dynamization was achieved by uniaxial and biaxial methods. Biaxial dynamization at the femoral neck and femoral shaft, plate sliding occurred on average of 11 mm and screw barrel sliding occurred on average by 9 mm (Figs 8.12A to C).
Figs 8.12A to C: Medoff's plate showing uniaxial and biaxial dynamization within the plate
179
When this device is used to stabilize reverse oblique fracture as recommended by Haidukewiych et al.27 the distal fragment is likely to get displaced medially and proximally as the fracture settles. The study of Haidukewiych et al.27 retrospectively reviewed 47 reverse obliquity fractures and found that 68 percent healed without a second operation, whereas 56 percent treated with 135° compression screw had loss of fixation. It is not a preferred implant for subtrochanteric fractures.
 
Intramedullary Devices
The implant of choice for most of the subtrochanteric fractures today is cephalocondylar nailing. Intramedullary (IM) fixation offers mechanical, technical, and biological advantages over plate and screw fixation. Intramedullary devices are introduced by closed procedure with indirect fracture reduction, maintaining vascularity of the fracture zone, with less disruption of fracture hematoma.28,29 Reaming stimulates periosteal reaction and generates debris that serves as autogenous graft material at the fracture site.
IM nailing of any variety has several advantages:
  1. IM nails are subjected to smaller bending loads than the extramedullary devices since the intramedullary canal is closer to the central axis of the femur, and hence less vulnerable to fatigue failure.
  2. IM nails act as load-sharing devices in fractures that have cortical contact of the major fragments. If the nail is in dynamic load, it acts as gliding splint and allows continuous compression when the fracture is loaded and may allow earlier postoperative weight-bearing and rehabilitation.
  3. Stress shielding and cortical osteopenia seen after plate fixation is avoided with IM devices.
  4. Refracture after removal of nail is rare.
Intramedullary devices are centromedullary (conventional femur nail), condylocephalic (Ender's nail) or cephalomedullary,6 which include Russell-Taylor reconstruction nails, Gamma nails, and PFN.
 
Ender's Nailing
Ender's nails have been extensively used in the past for the stabilization of intertrochanteric and subtrochanteric fractures with varying results.30,31 These flexible nails are inserted from the femoral condyle by retrograde method into the femoral canal in a stacked fashion up to the femoral head to provide fracture stability. These flexible nails may require additional fixation by cerclage wires for axial and rotational stability. The theoretical advantages of Ender's nails include limited surgical exposure, less blood loss and decreased operative time compared with plate screw fixation (Figs 8.13 and 8.14).180
Fig. 8.13: X-ray showing comminuted subtrochanteric fracture treated by Ender's nail, showing good union at the end of 6 months
Figs 8.14A to C: Three different types of fixation
High complication rates were reported with the use of Ender's nails, loss of fixation, malrotation deformity and knee pain.2831 Early revision rates ranging from 10 to 32 percent have been reported.2832 Ender's nail is commonly associated with restricted movements of the knee and knee pain secondary to nail back-out. It is not a preferred implant.
 
Conventional First-generation Interlocking Nailing (Central Medullary)
Conventional statically locked first-generation intramedullary nails were commonly used as implants in the past for the treatment of subtrochanteric fractures and gave consistently excellent results with Type IA or IB fractures (Figs 8.15A to D).3335 Since the fracture is commonly comminuted and it may not be possible to achieve stable fixation by proximal locking screws of first-generation nails, reconstruction nails were developed.3643 Three types of reconstruction nails, Gamma nail, Russell-Taylor nail, and proximal femoral nail (PFN) were introduced for the stabilization of subtrochanteric fractures.181
Figs 8.15A to D: X-rays showing subtrochanteric fracture treated by first-generation nail—central medullary interlocking nails, showing good healing. Postoperative five years follow-up X-rays
 
Reconstruction Nails—Russell-Taylor Nail, Gamma Nail, PFN (Cephalomedullary Nails)
Nailing interlocking can stabilize any subtrochanteric fracture, regardless of the fracture pattern and degree of comminution. The second-generation reconstruction (Gamma-type) intramedullary nail is superior to the initial conventional first-generation intramedullary device, with the theoretical advantage of not requiring an intact lateral cortex. In addition, the Gamma intramedullary nail provides three-point fixation, and the medial location of the implant provides a more efficient load transfer. The nail also has a shorter lever arm, which decreases the tensile strain on the implant and reduces the risk of mechanical failure (Figs 8.16 and 8.22).
Figs 8.16A and B: The difference in the biomechanics by two different methods of fixation, eccentric by DHS and side plate and intramedullary hip screw with shorter moment arm, which is far superior
Additional theoretical 182advantages of the second-generation nail include controlled fracture impaction and the fact that its use allows a closed reduction with shorter operative time and less blood loss. Commonly, these devices are very useful in subtrochanteric fractures below the level of the lesser trochanter without involvement of the greater trochanter.
Conventional intramedullary nailing (centromedullary): First-generation nails that are inserted through the piriformis fossa are interlocked by oblique or transverse screws proximally in the subtrochanteric region for which attachment of the lesser trochanter to the proximal fragment is necessary.3335 However, cephalomedullary second-generation Gamma nail and PFN which provide fixation of the head and neck proximally can be used for stabilization of proximal femoral fractures. This procedure of cephalomedullary fixation was not indicated if the fracture extended into the piriformis fossa but it is now performed even if the piriformis fosse is involved. Proper precaution is taken to ream the proximal fragment over the guidewire in the conventional way and should not bypass this reaming with the hope that the nail will go through the fractured piriformis fosse. This precaution is necessary to avoid blasting and comminution of the trochanteric fragment during the introduction of the nail. If this precaution is not taken, at times the nail may not go through the tip of the greater trochanter and will enter through the fracture in to the distal fragment.
High rates of union have been reported by nailing interlocking for stabilization of subtrochanteric fractures.3336 Wu et al.34 reported subtrochanteric fractures stabilized by interlocking nailing with a union rate of 87.1 percent and complications of nonunion, nail breakage and malunion in 13 percent cases. Wiss and Brien35 reported the results of closed nailing interlocking in 95 subtrochanteric fractures with union rate of 95 percent and concluded that closed interlocking nailing is the treatment of choice for subtrochanteric fractures. French and Tornetta36 reported the results of 45 subtrochanteric fractures treated by cephalomedullary reconstruction nails with 100 percent union rate with intraoperative complications of varus malreduction in 13.5 percent cases. There were no implant failures and 96 percent patients obtained more than 120° of knee motion.
Gamma nail, which has a 12-mm lag screw with a grooved shank that articulates with an intramedullary nail.3744 A set screw prevents rotation of lag screw but allows backing out through the nail. The proximal femur is aggressively reamed by gradual serial reaming to accommodate an intramedullary nail with a diameter of 17, 18 mm proximally and about 11 to 12 mm in the diaphysis. An appropriate diameter 10 to 12 mm intramedullary nail is used and placed in the canal by simple manual force only. Lag screw insertion into the femoral head is done through outrigger guides like sliding hip screw. Central positioning of guidewire in the femoral head in lateral view can be achieved by elevating the jig to correct the sag of the femoral shaft and the limb should be abducted to correct the coxa vara to achieve good 183center position in AP view and then the guide wire should be passed in the femoral neck and head. The set screw is inserted over the top of the nail and tightened until an audible snap is heard. Subsequently axial traction should be released and distally the nail should be interlocked through the jig (Figs 8.17 to 8.19).
These cephalomedullary intramedullary nails use different point of entries, trochanteric nails (Gamma nail) have a trochanteric entry, whereas in Russell Taylor nail entry through a piriformis fossa is required (Figs 8.20 and 8.21).45,46 A nail that uses a trochanteric starting point would result in less blood loss, shorter duration of surgery, smaller incision length, and fewer intraoperative complications, and would be easier to use than a nail that uses a piriformis fossa starting point.45 The ideal starting point for nail placement in proximal femur fractures is controversial. Trochanteric entry may damage the gluteus medius insertion on the greater trochanter, whereas the piriformis fossa, although in line with the medullary canal, may be difficult to reach, especially in obese patients.4547 A trochanteric entry point seems easier to reach, should necessitate a smaller incision, and lessens operating room time. In addition, trochanteric entry seems less likely to separate nondisplaced fractures at the level of the piriformis fossa.4547
Figs 8.17A to C: X-ray showing unstable intersubtrochanteric fracture treated by Gamma nail
Figs 8.18A to E: X-rays showing comminuted unstable intersubtrochanteric fracture treated by Gamma nail, good healing at the end of 11 months
184
Figs 8.19A to F: X-rays showing comminuted unstable subtrochanteric fracture treated by Gamma nail, good healing at the end of 6 months. Clinical photographs showing closed procedure, with scar of point of entry and interlocking screw
Figs 8.20A to E: Pathological subtrochanteric fracture femur right side in a 45-year-old female with fibrous dysplasia with impending fracture, left side treated by open surgery of fixation by Russell-Taylor interlocking with bone grafting right side and closed procedure left side
185
Figs 8.21A to C: Ipsilateral subtrochanteric and shaft fracture treated by Russell-Taylor reconstruction nail
Figs 8.22A and B: The theoretical biomechanical advantages of intramedullary devices include a shorter lever arm
With the critical analysis of entry point Ostrum RF et al.46 concluded that the tip of the trochanter, or even slightly medial, anteroposterior fluoroscopy is recommended as the universal starting point for these nails and this tip starting point led to the most neutral alignment regardless of the nail used. The analysis by Ostrum et al. (2005)46 of five trochanteric intramedullary nails with different proximal bends and three different starting points in the greater trochanter showed that the tip of the trochanter is the “universal” starting point.
Use of a cephalomedullary device is more complex when a subtrochanteric fracture has significant trochanteric and piriformis fossa comminution. In 186these situations, insertion of the nail through these regions may precipitate further displacement of the intertrochanteric components of the fracture. When there is fracture extension into the entry site, the nail may displace posteriorly through the fracture site. Studies have demonstrated excellent clinical and radiographic outcome with the use of cephalomedullary devices in fractures involving the entry point. Barquet et al.43 experienced no difficulty in placing a long Gamma nail in fractures with comminution of the piriformis fossa.
Technical disadvantages of intramedullary devices relate to the deforming forces acting on the proximal fragment. Abduction of the proximal fragment makes finding a starting point difficult and often results in lateralized guide wires and reamers. In addition, flexion of the proximal fragment by the iliopsoas can precipitate excessive reaming of the posterior cortex of the proximal fragment. Adjunct techniques to obtain and maintain reduction for passage of the intramedullary device may be necessary. These include pointed trocars, fracture manipulation with Schanz pins, or opening of the fracture site with provisional fixation. Residual apex anterior angulation with flexion of the proximal fragment may still be seen after intramedullary fixation of the subtrochanteric fractures and represents a disadvantage of these implant devices. A few authors recommend lateral positioning of the patient with the traction, for nailing of subtrochanteric fractures (Figs 8.23A to F). By flexing the affected extremity at the hip, reduction of the fracture can be facilitated readily and can allow for easier nail insertion.
Since it is a closed procedure usually performed on the traction table, the positioning of the patient tends to produce varus angulation. This can be overcome by increasing the traction to maintain fracture reduction. Fracture reduction in an acceptable position is a prerequisite for closed nailing interlocking. The proximal fragment can be manipulated by a special instrument in the desirable position and maintained while passing the guide wire and during reaming with the help of this device. Limitations and complications of the first-generation Gamma intramedullary nails led to changes in the design of these devices.38,40 The changes incorporated in the second-generation intramedullary nails, such as the Gamma Asia Pacific nail, Trochanteric Gamma nail (TGN), included a decrease in the distal diameter to 11 mm, a decrease in the valgus offset to 4°, decrease in the proximal diameter and shortening of the length (Figs 8.24A and B).4144 Almost all of the reported fractures occurred with the earliest intramedullary device, the Gamma nail, which was manufactured with a 10° valgus offset. This, together with surgeon inexperience, and an attempt to fill the canal with large-diameter nails, was thought to contribute to the high fracture rates reported initially. In their meta-analysis, Parker and Pryor48 reported surgical femoral fracture rates of 0–12 percent and postoperative fracture rates of 0–10 percent with the first-generation Gamma nail. The inherent stiffness of this implant shields the proximal-medial cortex and transfers loads to the distal part of the shaft.187
Figs 8.23A to F: X-ray showing subtrochanteric transverse fracture treated with PFN
Figs 8.24A and B: Schematic diagram of a first-generation Gamma nail and second-generation Gamma nail (A) Old design; (B) New design AP
188
This creates a stress riser at the transition of the nail tip and has led to cortical hypertrophy, which has been noted radiographically. The Gamma nail fell into disrepute initially because of stress fractures at the tip of the nail,3741 which led to the modification of original Gamma nail and use of the long Gamma nail.43 The second-generation nails also require greater forces to initiate sliding than do the sliding hip screws (Figs 8.16A and B).
The Gamma nail was developed in the past decade. This device combines a screw to the head of the femur with an intramedullary rod, offering, theoretically, the advantages of the sliding screw and intramedullary nailing.42,43 It allows guided impaction and decreases the lever arm of loading force. All patients and patients over the age of 60 years with subtrochanteric fractures, after recording their premorbid mobility, medical disease and social background should be subjected to the operative procedure. The problems of varus displacement and protrusion of the device into the hip joint are rarely encountered. The advantages of these implants are improved fixation of proximal fragment and resistance to the medial migration of the shaft. The impaction and early patient mobilization are supposed to restore medial cortical bony buttress even in comminuted fractures. It provides intramedullary fixation of both proximal and distal fragments in otherwise weak and porotic bone that can poorly tolerate a plate and screw and by intramedullary location the device has decreased bending movement as compared with plates. This method is also a treatment of choice in young patients with high-energy subtrochanteric fractures, which might be comminuted, in otherwise normal bone. The fixation is very stable and allows early mobilization, controlling the length and rotational stability of the limb. In a series published by Barquet et al.43 the rate of union was 100 percent with a high rate of restitution to preinjury status. The study concluded that closed reduction and long Gamma nailing of intertrochanteric-subtrochanteric fractures enables the orthopedic surgeon to treat these fractures with a minimally invasive procedure and a negligible rate of mechanical complications (Figs 8.25 and 8.26). Accurate measurement of alignment of the femoral neck in relation to the shaft using plain radiographs is difficult, and is dependent upon patient positioning and radiographic technique. Nevertheless, several authors report that varus malalignment is common after the use of cephalomedullary nails for proximal femur fractures.36,45,49,50
Insufficient reaming of the neck and proximal femoral fragments can result in lateralization of the shaft at the time of nail placement, which may also lead to varus deformity in the proximal fragment.45 Cephalomedullary nails offer surgeons the ability to restore length, alignment, and rotation with minimal soft-tissue dissection with low rate of varus malalignment.5153 Boldin et al.51 concluded in their study that with careful surgical technique with minimal invasive procedure the PFN can reduce the high complication rate (Figs 8.27A to C).189
Figs 8.25A to E: X-rays showing comminuted unstable subtrochanteric fracture treated by trochanteric Gamma nail, good healing at the end of 5 months
Figs 8.26A to D: (A and B) X-rays showing comminuted unstable subtrochanteric fracture with posterior dislocation treated by long extended Gamma nail; (C and D) Comminuted unstable subtrochanteric fracture treated by closed reduction and long Gamma nail
Figs 8.27A to C: Ideal reconstruction nail. No deformity of varus and external rotation
190
All these reconstruction nails have proximal interlocking fixation that gains purchase in the femoral neck and head.
 
Discussion
When the medial cortex is deficient, nailing may improve the result but varus and external rotation deformity is seen very often though the fracture unites. In the early phases of the introduction of the Gamma and PFN nail, concentration was mainly on negotiation of the nail from the proximal fragment to the distal fragment and passing the screws in the center of the head. The exact alignment of the fragment and reconstructing the preinjury anatomy was not paid enough attention. In follow-up X-rays these radiological deficiencies were detected, and patients walking about with restriction of internal rotation and Trandenburg gait were the observations which attracted more scrutiny of the results.
Now a few points are very clear, reduction with anatomical restoration is the primary aim of any fracture treatment. Subtrochenteric fractures have two different patterns:
  1. Proximal subtrochanteric: This is generally a high-velocity injury in younger patients with classical external rotation, abduction, and flexion of the proximal fragment. It is difficult to anatomically reduce with closed methods and when treated with nailing after closed reduction leaves external rotation deformity and varus shortening as end results.
  2. Distal subtrochanteric: This is generally a low-velocity injury and is seen more often in elderly porotic bones, with good reduction obtained by closed methods and is ideally suitable for treatment with cephalocondylar nails, PFN or Gamma nail (Figs 8.28 and 8.30).
Earlier it was felt that the medial cortex continuity was important only for 95° implant and if it was deficient, medullary implant should be used, which will work despite discontinuity of the medial cortex. This has not stood the test of time. Now we feel that the medial cortex continuity either by intact bone or by bone graft is a primary requirement for success of the subtrochanteric fracture fixation by 95° or medullary devices (Figs 8.29A and B).
Early operative treatment of subtrochanteric fractures reduces mortality and morbidity (Laskin, Gruber and Zimmerman, 1979,54 Cedar, 1980,26 Nue Moller et al. 1985,55 and Pillar et al. 198856) giving best chance of early independence and reducing the risks of prolonged bed rest. For nearly 40 years, the sliding hip screw and plate were the standard treatment for intertrochanteric fractures of the femur and its indication was extended for fixation of subtrochanteric fractures. In patients with stable fractures, the implant produces excellent results. However, in patients with unstable fractures, the implant is associated with a greater prevalence of complications, particularly cutout and subsequent loss of reduction. For these reasons, there has been a sustained interest in the use of an intramedullary nail to treat 191intertrochanteric-subtrochanteric femoral hip fractures.
Figs 8.28A to C: (A and B) Varus and shorteing deformity; (C) a. – proximal subtrochanteric and b. – Distal subtrochanteric fracture
Figs 8.29A and B: (A) Varus tilting and shortening in proximal subtrochanteric fracture; (B) Correction achieved by open reduction and stabilization by angled blade plate
192
Figs 8.30A and B: Distal subtrochanteric fracture stabilized with closed reconstruction nailing
Biomechanical studies have shown that an intramedullary device shortens the lever arm, provides more load-sharing, and can be inserted through limited incisions.
The use of an intramedullary nail or a 95° screw-plate for the treatment of reverse oblique and transverse intertrochanteric fractures was evaluated in a prospective, randomized study by Sadowski et al.57 Nineteen patients received a 95° dynamic condylar screw, and 20 patients received a PFN. Implant failure or nonunion occurred in seven of the 19 patients who had been treated with a 95° screw-plate. Only one of the 20 fractures that had been treated with an intramedullary nail did not heal. Although the numbers were small, the authors concluded that an intramedullary nail rather than a 95° screw-plate should be employed for the fixation of reverse oblique and transverse intertrochanteric-subtrochanteric fractures in the elderly.
Sliding nail plate system gives good results for both stable and unstable subtrochanteric fractures (Ecker, Joyce and Kohl, 1975,58 Doppelt, 1980,59 Jensen Sonneholm and Tondevold, 1980,60 Waddell, 1979,6 Herrlin et al. 198961) with reported complication rates of 3–15 percent. Their strength is adequate for the physiological load of a normal gait (Kaufer et al. 1974,62 Jensen, 1980,60 Larsson et al. 198863). Complications such as superior cutting-out are related to the position of the lag screw (Doherty and Lyden, 1979,64 Manoli, 1986,65 Simpson et al. 1989,66 Davis et al. 199067). Penetration of the lag screw is due to its failure to slide (Matthews et al. 1981,68 Simpson et al. 198966) and the rare lateral pulling out of the side-plate is caused by varus movement acting on the screws (Matthews et al. 1981,68 Wolfgang et al. 1982,69 Amis et al. 198770).
Baumgartner et al. 199871 found no significant differences between intramedullary sliding hip screw and compression hip screw, even when compared in unstable fractures. Whereas Hardy et al.199872 showed that 193intramedullary sliding hip screw was associated with improved early mobility and significant decrease in limb shortening in unstable fractures.
The Gamma nail attempts to combine the advantages of the sliding lag screw with those of intramedullary fixation while decreasing the moment arm as compared with that of the sliding nail plate. It can be inserted by closed procedure, which retains the fracture hematoma, an important consideration in fracture healing (Mckibbin, 1978,73 Latta et al. 198074), and reduces both exposure and dissection. Insertion of Gamma nail was accomplished by small incision with little dissection with the advantages of closed fixation for diaphyseal fractures (Kempf, Grosse and Beck, 1985,75 Klemm and Bomer,1980,76 Wiss et al. 1986,77 Zuckerman et al. 1987,78 Brumback, 198879). Presently the Gamma nail has been modified (AP Gamma nail) basically meant for Asian population.41 Gamma nailing achieves stable fixation of subtrochanteric fractures with equal length and rotational stability with the following advantages: less surgical trauma, less screening time, less blood loss, early rehabilitation, ease of implantation, early weight-bearing (Figs 8.31A and B).
Modified Gamma nail (AP Gamma nail) basically meant for the Asian population has the following changes in its size and dimensions:
  • Proximal diameter 17 mm
  • 160 mm long
  • 11 mm distal diameter
  • 4° mediolateral angle
Whereas the only change in the Trochanteric Gamma Nail (TGN) is the reduction in the proximal diameter to 15.5 mm.
All reconstruction nails achieve stable fixation, restore subtrochanteric length and rotational stability with the following advantages:
  • Less surgical trauma
  • Less screening time
Figs 8.31A and B: Reconstruction of deficient medial cortex achieving good alignment
194
  • Less blood loss
  • Early rehabilitation
  • Ease of implantation
  • Early weight-bearing
 
Complications
 
Loss of Proximal Fixation
Following are the frequent causes of failure of sliding screw:1
  1. Cutting out of the compression screw from the femoral head
  2. Pulling off of the side plate from the femoral shaft
  3. Disengagement of the sliding hip screw from the barrel
  4. Failure of the hip screw.
Migration of the compression hip screw with cut-out from fthe emoral head remains the most common mechanical complication after surgical fixation. A review of severe unstable fractures revealed a 56 percent failure rate of cut-out and nonunion. Similarly, there may be metallic fatigue fracture of the implant, either at the junction of DHS assembly or even of Gamma nail at the site of hole of lag screw.
Mechanical complications: A few examples of implant failure–mechanical and biological failure (Figs 8.32 to 8.34).
In proximal type of high-energy fractures the cephalocondylar nail often produces a deformity. And hence we feel that if anatomical reduction is not obtained, there should be no hesitation in doing open reduction and using 95° DCS or condylar plate for this type of subtrochanteric fracture (Figs 8.35 to 8.37).
 
Fracture Shaft Femur
Femoral shaft fracture was a complication of the use of first-generation intramedullary Gamma nails, with rates ranging from 2.2 to 17 percent and an overall rate of 5.3 percent in a meta-analysis.3739
Fig. 8.32: Medial defect filled with bone graft
195
Figs 8.33A to D: Breakage of implant due to deficient medial cortex
Figs 8.34A to C: (A) Failed PFN; (B) Conversion to bipolar long stem; (C) Cement leakage
Figs 8.35A and B: Nonunion 4 years treated with 95° DCS
196
Figs 8.36A to C: Results after medial defect filled with bone substitute and graft healed in 6 months
Figs 8.37A and B: X-rays of two patients showing bending at the assembly of DCS, an effect of early weight-bearing
Bridle et al.37 found that two-thirds of the femoral fractures in their series were in patients with a 16-mm diameter implant. In their meta-analysis, Parker and Pryor48 reported surgical femoral fracture rates of 0 to 12 percent and postoperative fracture rates of 0 to 10 percent with the first-generation Gamma nail.
The rate of cutout of first-generation intramedullary nails from the femoral head has ranged from 2 to 4.3 percent, with a meta-analysis showing a mean rate of 3.1 percent. Thigh pain has been reported to occur in 17 percent of patients treated with a first-generation nail, and Hardy et al.72 found a relationship between thigh pain and the use of two distal interlocking screws. In addition, Hardy et al.72 showed that a device with a slotted distal hole caused less thigh pain than did one with the standard interlocking holes.197
 
Nonunion–Delayed Union
Nonunion of comminuted subtrochanteric fractures is infrequently observed as one of the complications which is more common than hardware cut-out. The cortical bone with diaphyseal involvement delays the union and at times more likely than in intertrochanteric fractures. Most reports of nonunion are associated with instability or loss of reduction with deformity and pain and failure of implants1 (Figs 8.38 to 8.41).
 
Malunion
Malunion of subtrochanteric fractures is frequently noticed, even with best of the treatment and fixation. Shortening, coxa vara is commonly noticed in subtrochanteric fracture femur. Patients with mild shortening can be treated with compensation shoe but with gross limb length discrepancy it might be desirable to achieve the correction by surgical intervention with procedures like corrective osteotomy.
Figs 8.38A and B: (A) Subtrochanteric fracture fixed by DCS in malposition mainly because of poor implant of 90° and screw at the fracture site; (B) Correction of malposition by 95° plate removal of screw and incorporation of bone graft medially
Figs 8.39A to D: X-rays showing comminuted unstable subtrochanteric fracture treated by sliding hip screw, which broke at the barrel blade plate junction, revised by DHS with medialization of the femoral shaft
198
Figs 8.40A to G: X-rays showing unstable subtrochanteric fracture treated with standard Gamma nail, which broke at the proximal hole for the hip screw in the nail with collapse and healing of fracture in the varus position
Figs 8.41A to D: X-rays showing angled blade plate – implant failure – bone graft. Mandatory angled blade plate revised with bone grafting showing bony healing at 8 months
 
Painful Hardware
Painful hardware after open reduction and internal fixation is probably under-reported in studies of hip fracture.199
Figs 8.42A to H: X-rays showing intersubtrochanteric fractures fixed by DHS with failure of implants and refracture resulting in malunion. Only implants removed since, functionally patient had good movements and advice of corrective osteotomy was refused
The pain is often thought to result from a backed-out compression screw irritating femoral musculature, but nonunion must be actively excluded as a cause of residual pain. Two series have reported two patients each with unstable fractures who required removal of compression hip screws one year postoperatively because of thigh pain (Figs 8.42A to H).72
 
Conclusion
Subtrochanteric fractures are difficult to manage and need surgical fixation most of the time. The simple fractures can be easily dealt with by simple surgical procedures like AO angled blade plate or dynamic hip compression screw. However, many times the injury is an outcome of high-energy trauma where the fracture is severely comminuted in a young patient with good quality of bone. All displaced and unstable subtrochanteric fractures either in porotic bone (elderly patients) or comminuted unstable fractures need very aggressive treatment of surgical fixation. After achieving a stable fixation by any of the types of reconstruction nails, the patients are mobilized early and simultaneously complications like shortening, coxa vara can be prevented. This is well managed by closed procedure of cephalocondylar nail of any type, where the proximal fragment is well controlled by a sliding hip screw 200and distally the nail is interlocked by two screws controlling the rotational instability. Varus deformity is the major complication of proximal fracture. Condylar or DCS is a good option if normal alignment is not obtained by closed or even open methods while nailing. As nail cannot control; the entire displacements even if are corrected by joy stick, varus and external rotation deformity is common. DCS or condylar plate can avoid this. Medial cortical buttress is the key in both forms of treatment.
 
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  1. Roberts CS, Nawab A, Wang M, Voor MJ, Seligson D. Second generation in- tramedullary nailing of subtrochanteric femur fractures: a biomechanical study of fracture site motion. J Orthop Trauma 2002;16:231–8.
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  1. Amis AA, Bromage JD, Larvin M. Fatigue fracture of a femoral sliding compression screw-plate device after bone union. Biomaterials 1987;8:153–7.
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  1. Hardy DC, Descamps PY, Krallis P, et al. Use of an intramedullary hip-screw compared with compression hip-screw with a plate for intertrochanteric femoral fractures: A prospective, randomized study of one hundred patients. J Bone Joint Surg Am 1998; 80:618–30.
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  1. Wiss DA, Fleming CH, Matta JM, aurk D. Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. Clin Orthop 1986;212:35–47.
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  1. Brumback RJ, Uwagie-Ero 5, Lakatos RP, et al. Intramedullary nailing of femoral shaftfractures. Part II: fracture-healing with static interlocking fixation. J Bone Joint Surg [Am] 1988;70-A:1453-62.

Ipsilateral Femoral Neck and Shaft Femur Fractureschapter 9

A combination of ipsilateral hip and shaft fractures is an extremely rare injury. Both, the fractures of the proximal femur and fracture of the shaft of femurs are independently common but concurrent femoral neck fractures with ipsilateral femoral shaft fractures are reported in 2 to 5 percent of patients with fracture shaft femur.14 There is a wide variety of combination fractures of the proximal femur, like subcapital, transcervical, basal (femoral neck fractures), intertrochanteric and subtrochanteric fractures with shaft fractures on the same side. Combination of neck fractures occurs more often than intertrochanteric fractures. Delaney and Street first described this combination injury in 19535 and subsequently many authors described this injury.2,3,611
The fractures of the ipsilateral femoral neck and shaft are a rare combination of injuries. The diagnosis of this combination of fractures is missed in 20 to 50 percent cases, mainly because of failure to radiographically evaluate the hip joint and the entire femur when there is fracture shaft of femur.3,4,8,1215 Attention is easily drawn to more dramatic shaft fractures, while the possibility of another fracture in the same femur is not considered and thus missed. This unusual combination of fractures is seen in patients involved in high-velocity injuries.4,5 Sometimes the fracture neck femur is detected on the operation table when the patient is taken for antegrade femoral nailing and the fracture is noticed while taking the point of entry for nailing interlocking. A few fracture neck femurs may be iatrogenic injuries created at the time of intramedullary nailing. When they are discovered it may be uncertain whether they were present before the operation or occurred during the procedure. Failure to take appropriate radiographs, external rotation of the shaft of the femur and the presence of a subclinical occult fracture may account for preoperative misdiagnosis.16 It might be possible that many of these injuries were unrecognized preoperatively because of poor X-rays or no X-rays done earlier, and attributed to or propagated by surgical procedure. Plain X-ray of the proximal femur must be obtained as a part of the initial evaluation followed by fluoroscopic evaluation in each and every patient of fracture shaft femur. Ideally, X-ray femur must include the hip and knee joints. Proper clinical examination of the hip joint for 206injury in a patient of fracture shaft femur is essential. Fracture neck femur detected during nailing may be initially missed or may occur during the preparation for point of entry17 during nailing, or lateral insertion of nail or wrong point of entry.18,19 However, femoral neck should be checked before operation by a good quality X-ray or computed tomography (CT) if required in doubtful cases. A CT scan of the neck taken before nailing or fluoroscopic examination of the femoral neck is needed if CT is not available, to allow a full assessment of the fractures before operation.12,19 Displacement of such a fracture is often regarded as an iatrogenic fracture.15 A neck fracture may be diagnosed immediately after nailing or several days later when the patient is mobilized, and several cases have been reported as iatrogenic fractures.15 The faulty introduction of a femoral nail may cause an iatrogenic fracture of the femoral neck, but many so described are probably due to displacement of an incomplete or undisplaced fracture during nailing.20 The shaft femur fracture in this combination injury is usually in the mid-shaft and is often comminuted. This comminuted mid-shaft femoral fracture secondary to axial loading should alert the surgeon for the associated neck femur fracture.21 In this combination injury the knee and femoral shaft absorb most of the impact of energy, thus reducing the energy transferred to the neck, which will minimize the displacement of the associated fracture neck femur which accounts for missed and delayed diagnosis of fracture neck femur because of minimal symptoms.2123
 
Mechanism of Injury
Almost all these combinations of injuries result from high-energy trauma, secondary to motor vehicle accidents.14,6 In a study by Wolfgang,24 in 144 high-energy compression fractures of the shaft femur, there were 43 patients with associated fracture neck femur. However, in a few cases the injury might result from falls from height, motorcycle accidents and in pedestrians who meet with motor vehicle accidents. Hence, one has to be careful while dealing with cases, especially in:
  • Unconscious patient
  • Polytrauma patient
  • Multiple fractures
  • Segmental fractures.
Proper X-rays are essential for the evaluation and in addition to shaft femur it must include hip and knee joints. If in doubt, internal rotation view of the hip, X-ray pelvis and CT should be performed before the patient is subjected to surgery. Adequate management has to be planned only after radiological confirmation and supplementary investigations.
 
Management
Ipsilateral femoral neck and shaft fractures are best treated by surgical stabilization. Despite the advances in internal fixation methods this 207combination of fractures continues to create a dilemma for the best option amongst the internal fixation devices and timing of surgery. Conservative treatment is rarely indicated and surgical fixation remains the gold standard. Conventional teaching indicates that the femoral neck fracture is potentially the more problematic part of this injury. Femoral neck fractures in young patients are considered an orthopedic emergency.
The issue is which fracture should have the optimal treatment, which may compromise the optimal treatment of the other injury.
However, Alho,25,26 Watson, and Moed27 have suggested that femoral shaft fracture was the main determining factor of the patient's overall outcome. Furthermore, the risk for complications is greater in the treatment of this combination injury pattern than for single-level fracture. In the retrospective study of Watson and Moed27 patients with femoral shaft nonunion required more operative procedures to achieve union when compared with patients with femoral neck nonunion. Six of the eight (75%) cases of femoral neck nonunion occurring in these 13 patients developed after the use of a second-generation, reconstruction-type intramedullary nail. The femoral neck nonunion healed after either valgus intertrochanteric osteotomy (seven patients) or compression hip screw fixation (one patient). The femoral shaft nonunion proved to be more difficult to treat than expected, with some patients with femoral shaft nonunion requiring more than one operative procedure to achieve union. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications. We agree with other investigators that the complications involving the shaft fracture of this injury pattern are not uncommon. However, the shaft portion of this injury may not receive attention on priority, the thought being as usual the shaft femur fracture will be easier to handle, since the rate of nonunion of femoral neck fracture and osteonecrosis are very high if the fracture is not anatomically fixed early. Swiontkowski et al.2,3 reported a 20 percent incidence of avascular necrosis (AVN) in young patients despite aggressive treatment whereas Protzman and Burkhalter28 reported AVN in 86 percent and nonunion in 59 percent of young patients with femoral neck fracture treated with open reduction and internal fixation. The rationale of definitive fixation of the femoral neck as the initial step in surgical fixation is based on technical and biological considerations.21 It is technically difficult to fix the fracture neck femur in the presence of antegrade femoral nail or stable fixation of the femoral neck will not allow passage of the standard antegrade femoral nail. Hence, either one will have to use retrograde nailing interlocking and fix fracture neck femur with multiple screws or DHS or use second-generation reconstruction nail for stabilization of both the fractures.22,23 However, because of concern about the suboptimal fixation of comminuted shaft fracture, a few authors prefer to fix femoral shaft fractures first.1,7,2430 Femoral shaft fractures are frequently unstable rotationally and axially and are best managed by standard reaming 208interlocking nail. Adequate fixation of femoral neck fracture is achievable with the use of supplementary screws, though it might be difficult. For this miss-a-nail technique with the use of Sirus nail has been invented. However, with the advent of cephalomedullary nails, second-generation reconstruction nails, both the fractures can be effectively fixed1,7,13,15,26,2937 with good results.
There are multiple treatment options:
  1. Reconstruction nail
    1. Gamma nail33,34
    2. Russell Taylor nail31, 35
    3. Proximal femoral nail (PFN)32,36
  2. Lag screw multiple cancellous screw for neck with retrograde nailing interlocking
  3. Sliding hip screw—DHS with DCP for shaft stabilization
  4. Sliding hip screw—DHS with retrograde nailing
  5. Miss-a-nail technique by Sirus nail
  6. Lag screw multiple cancellous screw for neck with DCP for shaft fracture
  7. Various other combinations.
The most commonly used method of fixation is antegrade intramedullary femoral nailing for shaft fractures with multiple screw fixations for neck fracture.13,14,29,31 This is achieved either by miss-a-nail technique or by using Sirus nail. However, screw fixation of fracture neck femur for compression is a priority and shaft femur can be treated either by retrograde nailing or fixation by dynamic compression plate.22,27
Intramedullary nailing interlocking technique has changed the management of these fractures. The first-generation interlocking nails did not afford adequate fixation for combination injuries but second-generation nails are basically designed to take care of simultaneous fixation of both the fractures.3239 There are many reports of the use of reconstruction nailing for the fixation of these ipsilateral combination injuries.3040 The attractiveness of this type of fixation was that closed nailing avoiding extensive open reduction procedures could treat the complete spectrum of femoral shaft fractures.3238 The proximal end of the nail is designed to accommodate two lag screws that gain purchase in the femoral head and neck of the femur.30,32,33,3638 The fixation of proximal femoral fractures also acts as proximal locking for interlocking fixation of the shaft. The operative technique and use of these devices are technically more demanding than routine nailing interlocking. Correct rotation of the nail and direction of anteversion for lag screws in the femoral neck has to be properly guided for proximal fixation.34,35 The possibility of displacement of femoral neck fractures during surgical fixation has to be considered while fixation by reconstruction nail, hence one may have to consider temporary fixation of femoral neck injury with temporary K-wire or guidewire or one screw to begin with.209
 
Gamma Nail (Figs 9.1 to 9.3)34,35
Fig. 9.1: Ipsilateral basal fracture neck femur with shaft fracture treated by Gamma nail—11 months postoperative
Fig. 9.2: Combination injury subtrochanteric fracture with shaft fracture treated by long Gamma nail—3, 10 years follow-up
210
Fig. 9.3: Ipsilateral subcapital fracture neck femur with shaft fracture treated by Gamma nail—8 years follow-up
 
Russell Taylor Nail (Fig. 9.4)32,35,36,40
Fig. 9.4: Ipsilateral trochanteric and shaft fracture X-ray of Russell Taylor reconstruction nail
211
 
Proximal Femoral Nail (Figs 9.5 and 9.6)
Fig. 9.5:
Figs 9.5 and 9.6: Ipsilateral trochanteric and shaft fracture treated by proximal femoral nail
212
 
Multiple-Screw for Neck with Retrograde Nailing Interlocking (Figs 9.7 to 9.9)22,27
Fig. 9.7: Multiple-screw fixation for fracture neck femur with retrograde nailing for shaft femur with primary loss of bone. Treated by bone grafting in second stage at 4 weeks. The patient developed stress fracture just below the heads of the cancellous screw and above the tip of the nail, treated by revision with exchange nail by longer retrograde nail and removal of one screw. Final X-ray at 6 months showing good healing of both fractures with solid callus
Fig. 9.8: Multiple-screw fixation for fracture neck femur with retrograde nailing for shaft femur in a single bone
213
Fig. 9.9: Multiple-screw fixation for fracture neck femur with retrograde nailing for shaft femur
 
DHS with DCP (Fig. 9.10)22,25,26
Fig. 9.10: X-rays showing stabilization of cervicotrochanteric fracture by DHS and shaft fracture fixed by DCP
214
 
DHS with Retrograde Nail (Fig. 9.11)
Fig. 9.11: X-ray showing stabilization of intertrochanteric fracture by DHS and shaft fracture fixed by retrograde nail
 
Miss-a-Nail Technique (Fig. 9.12)13,14,29,31
Fig. 9.12: X-ray showing stabilization of cervicotrochanteric fracture and shaft femur by miss-a-nail technique
215
 
Lag Screw—Multiple Cancellous Screws for Neck with DCP for Shaft Fracture (Fig. 9.13)
Fig. 9.13: X-rays showing stabilization of fracture neck femur and ipsilateral shaft femur by cancellous lag screw and DCP
 
Postoperative Protocol
Patients should be mobilized quickly. Rehabilitation should begin within two to three days after fixation. Nonweight-bearing hip knee exercises should be started and patient should be encouraged for nonweight-bearing crutch-walking. Weight-bearing is delayed especially to protect the fracture neck femur. In most of the cases partial weight-bearing should begin between six to eight weeks after fixation and full weight-bearing depending upon the fracture neck fixation and comminution of fracture shaft femur. Early progression to weight-bearing facilitates callus formation and fracture union. The delay in weight-bearing ambulation may have a detrimental effect on those who were treated with undersized, less stable nail. All nails were passed after reaming of the diaphysis of the femur and no unreamed nails were used in our series. We agree with other investigators that larger, appropriately fitting reamed nails may be more effective to achieve the benefit of early weight-bearing to promote fracture healing.
 
Complications
  1. Nonunion
  2. Malunion
  3. Avascular necrosis of the femoral head
  4. Implant failure.
216
Femoral neck fracture nonunion or avascular necrosis of the femoral head has been reported in about 7 percent of these cases.2,3,28 To avoid these complications, priority is given to femoral neck fixation and hence intracapsular fractures are preferably fixed by lag screw or multiple cancellous screws.22,29
At times there might be nonunion of femoral shaft fractures. Hence, early intervention for bone grafting may be considered if delayed union is observed.
 
Conclusion
It is mandatory to take an X-ray of the hip and knee joint in any fracture shaft femur, may be at times CT pelvis is required.17 Priority of fixation should be given to femoral neck fractures and any combination of fracture fixation described above should be considered. Whenever planning for nailing interlocking, keep all types of third generation reconstruction nails ready, including Gamma nails or reconstruction nails as standby. Adequate inventories must be kept handy and ready, including DHS implants, cancellous screws and reconstruction nails.
 
References
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  1. Casey MJ, Chapman MW. Ipsilateral concomitant fracture of the hip and femoral shaft. J Bone Joint Surg Am 1979;61A:503-9.
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  1. Geissler WB, Savoie FH, Culpepper RD, Hughes JL. Operative management of ipsilateral fractures of the hip and femur. J Orthop Trauma 1989;2:297–302.217
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  1. Bennett FS, Zinar DM, Kilgus DJ. Ipsilateral hip and femoral shaft fractures. Clin Orthop 1993;296:168–77.
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Rehabilitationchapter 10

After a stable, anatomical reduction and fixation of proximal femoral fractures it becomes paramount to properly rehabilitate a patient so as to help him regain a productive life. Similarly, after prosthetic replacement quick mobilization of the patient out of bed is of utmost importance for excellent recovery. The continuous motivation of the patient is equally important to achieve a decent level of activity with time.
Early mobilization out of bed after hip fracture surgery is important to reduce the risks of thromboembolism, pulmonary complications, skin breakdown and decline in mental status. Mobilization also inspires confidence and encourages the patient on the road to recovery. Physical therapy should be started on postoperative day 1.
An acute care evaluation includes the review of diagnosis and surgical procedure, current medical status, range of joint motion, muscle strength, flexibility, status of upper extremities if any assisted devices are needed; patient's surgical dressings and wound care, and willingness to cooperate should also be noted.
Daily, depending upon the facility, the patient is assisted out of the bed into a leg dangling position followed by walking non-weight-bearing (or weight-bearing for prosthetic replacement patient) on the operated limb on day 1 after the operation. Specific instructions regarding mobility in bed are explained keeping in mind maintenance of limb alignment and joint position. This is followed by commencement of ambulation training. Patients with femoral neck fractures or intertrochanteric fractures treated surgically with prosthetic replacement or internal fixation are allowed to bear weight as tolerated. Weight-bearing status after a subtrochanteric fracture is dependent on the fracture pattern, fixation device used, amount of bone comminution, patient's age and bone quality.
If there are no orthopedic contraindications for unrestricted weight-bearing the patient's goals for ambulation are set as tolerated. The usual protocol is as:
  • Postoperative day 2: Walking with moderate assistance for 15 feet
  • Postoperative day 3: Walking 25 feet with minimal support220
  • Postoperative day 4: Walking 40 feet
  • Postoperative day 5: Stair climbing
Exercises and strength training are started with instructions for exercises in three positions: supine, sitting and standing. The exercises are administered to patient to tolerance on daily basis. Supine exercises include quadriceps exercises, heel slides, active assisted hip flexion, active-assisted straight leg raising, active hip extension and abduction and ankle pumps. Patients who have had internal fixation are allowed an unrestricted range of hip motion while those who have undergone prosthetic replacement are allowed 90° of hip flexion for six weeks in addition to the fact that hip adduction and internal rotation are also contraindicated if prosthetic replacement was performed through a posterior approach. In sitting position the exercises are started with active knee extension, self-assisted hip flexion with a towel, especially in those with internal fixation. Standing exercises include straight leg raises with the patient on parallel bars, hip abduction, hip flexion and quarter-knee bends. Exercises progress from active-assisted to active and then resistive. Repetitions are increased to enhance patient's endurance.
 
Adaptive Equipment
Adaptive equipment and assistive devices should be routinely prescribed for elderly patients with operated hip fractures. Ambulation devices are used to increase stability and lower the weight-bearing forces across the injured extremity.
 
Parallel Bars
These are rigid and do not have to be moved by the patient. This helps the patient to concentrate entirely on moving his lower limbs correctly. The distance should be adjusted between the bars such that elbows are in flexed up to 30°.
 
Walking Frames (Walker)
Usually this is avoided because it is difficult to change the gait acquired when the patient is asked to change to walking stick or a pair of crutches.
  1. Standard walking frame: Light, rigid, easy to use with four vertical aluminum alloy tubes held in a rectangle, with one side left open.
  2. Gutter frame: Main structure is the same as the standard frame but it has handles modified with gutters for the forearms to rest. This type is useful when the patient is unable or cannot extend his elbows fully because of weakness, deformity or plaster cast.
  3. Pulpit frame: Wider and higher than the standard frame with the top having a padded U-shaped ledge reaching the lower part of the chest. It is used by patients with deformity or weakness of the whole upper limb, for those who tend to fall backwards while walking.221
  4. Reciprocal walking frame: Same as the standard frame except that each side can be moved alternately as there are swivel joints in the front horizontal and vertical tubes. Stability of the patient is increased, as the frame need not be cleared off the ground while walking.
  5. Rollator: It has two wheels at the front and two short legs at the back with the rear legs directly under handgrips.
 
Crutches
Three main types of crutches are used:
  1. Axillary crutches: Consist of double upright joined at the top by a padded axillary portion; a handgrip and a nonslip rubber tip covering.
  2. Elbow crutches (Loftstrand crutches): Mostly made from a single adjustable tube of aluminum alloy to which are attached U-shaped metal cuffs to accommodate the forearms.
  3. Gutter crutches: Consist of a single tube of aluminum alloy with a short horizontal alloy gutter attached.
 
Walking Sticks
Single or tripod stick to be used on the uninjured side for the support and ease of walking.
223Index
Page numbers followed by f refer to figure
A Abduction displacement osteotomy – osteotomy Absorption of medial femoral cortex Acetabular cavity erosion Anatomy around trochanteric region Angled blade plate , , Anterior joint capsule and tendon of rectus femoris AO/OTA classification , , of proximal femoral fractures Arrangement of tensile and compression trabeculae Augmentation with bone cement Austin Moore hemiarthroplasty pins –, prosthesis replacement , Avascular necrosis in intertrochanteric fracture of femoral head Axillary crutches B Bent Gamma nail Jewett nail Bipolar hemiarthroplasty Blood supply of femoral head , Bone cement Boyd and Griffin's classification Broken Gamma nail prosthesis Brumback classification , indentation fracture Buck's traction C Calcium phosphate triphosphate Causes of painful hip Cement intrusion Cemented bipolar prosthesis replacement total hip replacement Cementing and fitting of prosthesis Cephalomedullary nails Cervicotrochanteric fracture neck femur Cervicotrochanterical fracture Classification of avascular necrosis Closed or open reduction and internal fixation reconstruction nailing Combination injury subtrochanteric fracture Comminuted intertrochanteric fracture subtrochanteric fracture unstable intersubtrochanteric fracture intertrochanteric fracture subtrochanteric fracture , , Complete exposure of acetabulum for removal of small fragments surgical dislocation of hip Complications of femoral neck fractures intramedullary hip screw PFN Compression hip screw , Compressive tension stress fractures Computed tomography Containment bracing Conventional first-generation interlocking nailing intramedullary nailing Coronally sectioned hip joint Coxa vara D Deep internervous plane venous thrombosis 224Delbet's classification of fracture neck femur in children , DHS with retrograde nail Dimon Hughston osteotomy technique , Dislocation , of hip with fracture femoral head Displaced femoral neck fractures intertrochanteric fracture lesser trochanteric fragment subcapital fracture , unstable comminuted intertrochanteric fracture intertrochanteric fracture Distal subtrochanteric fracture , Double angled blade plate Dynamic condylar screw plate E Elbow crutches Ender's nailing Entrapped acetabular fragment in hip joint Erosion of acetabulum Evan's classification system Exposure of fascia lata F Femoral head fractures , shear fracture Fibrous dysplasia Flip trochanteric osteotomy of greater trochanter Fracture angle displacement femoral head , with dislocation neck femur , , , and vascularity in adults in children shaft femur Fresh subcapital fracture Functional outcome G Gamma nail , , , , , , Garden's alignment index classification , Gluteus medius , minimus Gutter crutches frame H Hemiarthroplasty Heterotopic ossification Hip joint , Homan's retractors Hybrid total hip replacement I Impacted and undisplaced fracture neck femur fracture neck femur Impingement of hip screw Implant failure Incising deep fascia tensor fascia lata Infection , , Intensity of injury Intersubtrochanteric fractures Intertrochanteric fracture , , , , , , , , , , , femur fixation neck femur Intertrochanter-subtrochanter fracture Intramedullary device , hip screw sliding hip screws Ipsilateral basal fracture neck femur with shaft fracture femoral neck and shaft femur fractures subcapital fracture neck femur J Jensen-Michaelsen's classification , Jewett nail , , , K Kocher-Langenbeck incision Kyle's type classification , L Lag screw multiple cancellous screw 225Large posteromedial fragment Location of subtrochanteric fracture Loftstrand crutches Loss of fixation proximal fixation , reduction Lowell's lines M Magliato classification Magnetic resonance imaging Malunion Massie nail McLaughlin plate Mechanism of injury , , Medialization of femoral shaft Medoff's plate , , Method of calculating tad thromboprophylaxis Meyers’ procedure Miss-a-nail technique , Mixter artery forcep Modification of sliding hip screw Modular bipolar prosthesis Multiple cancellous screws , , , –, fractures pins screw fixation for fracture neck femur , screw for neck with retrograde nailing interlocking Muscle pedicle grafting Myositis ossificance N Nonunion of intertrochanteric fracture , O Open reduction and temporary fixation of fracture fragments of intertrochanteric fracture , split trochanter Operative steps of Gamma nailing sequential reaming , technique of surgical dislocation of hip Orthopedic Trauma Association classification Osteonecrosis , , , , , of femoral head , Osteopetrosis Osteosynthesis P Painful hardware , hip Parallel bars cancellous screws screw fixation Pathological subtrochanteric fracture femur Pauwel's Type III fracture neck femur – transcervical fracture neck femur classification , Percutaneous method Periprosthetic fracture of shaft of femur Pipkin's classification , Placement of DHS after reduction lag screw in femoral head Posterior dislocation of hip Post-traumatic osteonecrosis Premature physeal closure , Primary abduction osteotomy bipolar hip replacement cemented bipolar prosthesis total hip replacement medial displacement fixation total hip replacement uncemented total hip replacement Principles of treatment Prosthetic replacement , of fresh intertrochanteric fracture Protrusion acetabulii Proximal femoral nail , , , , , , subtrochanteric fracture Pulpit frame Pyriformis after osteotomy R Reciprocal walking frame Reconstruction nails Rectus femoris 226Reduction of fracture dislocation of hip with fixation of fracture Rehabilitation Resultant coxa vara Retrograde nail Revision of osteosynthesis for non-union of intertrochanteric fractures Role of external fixator Russell-Taylor classification , interlocking with bone grafting nail , , , reconstruction nail , S Salvage with Calcar replacement prosthesis Sciatic nerve palsy Segmental fractures Seinsheimer's classification , Shaft femur Sirus nail Sliding hip screw , , Smith Petersen anterior approach incision Stabilization of cervicotrochanteric fracture , fracture neck femur intertrochanteric fracture periprosthetic fracture Standard Gamma nail , walking frame Standardize acceptable fracture reduction Steinmann pin Steps in removal of AMP Stewart and Milford classification Stress fracture neck femur Subcapital fracture neck femur , , , Subtrochanteric fracture , , fixation transverse fracture T Technique of DHS fixation Thigh pain Thompson and Epstein classification Total hip arthroplasty , , replacement , Towel clip Traction table Transcervical fracture neck femur , Transepiphyseal fracture neck femur Transverse tension stress fractures Trochanteric Gamma nail osteotomy plate Types of fixation , osteonecrosis of femoral head U Uncemented total hip replacement Undisplaced fracture neck femur Unreducible intertrochanteric fracture Unstable comminuted intertrochanteric fracture intersubtrochanteric fracture , intertrochanteric fracture – subtrochanteric fracture Ununited subcapital fracture Use of bone grafts V Valgus osteotomy Vascularity around hip joint neck of femur of femoral head W Waddell's classification , Walking frames sticks Ward's triangle Watson jones Whitman's method of fracture reduction X X-ray pelvis Z Z-shaped capsulotomy of hip