Intertrochanteric Fractures

Surgical Management of Hip Fractures: An Evidence-based Review of the Literature. II: Intertrochanteric Fractures Kevin Kaplan, MD Abstract Ryan Miyamoto, MD Treatment of intertrochanteric hip fracture is based on patient Brett R. Levine, MD medical condition, preexisting degenerative arthritis, bone quality, Kenneth A. Egol, MD and the biomechanics of the fracture configuration. A critical review of the evidence-based literature demonstrates a preference Joseph D. Zuckerman, MD for surgical fixation in patients who are medically stable. Stable fractures can be successfully treated with plate-and-screw implants and with intramedullary devices. Although unstable fractures may theoretically benefit from load-sharing intramedullary implants, this result has not been demonstrated in the current evidence- based literature. ntertrochanteric hip fractures are treatment, although prosthetic re- Dr. Kaplan is Sports Medicine Fellow, Iextracapsular fractures of the placement is occasionally indicated. Kerlan Jobe Orthopaedic Clinic, Los proximal femur involving the area The major difficulty stems from the Angeles, CA. Dr. Miyamoto is Sports between the greater and lesser tro- combination of the presence of often Medicine Fellow, Steadman Hawkins chanter. Such fractures that extend osteopenic bone and the adverse bio- Clinic, Vail, CO. Dr. Levine is Adult into the area distal to the lesser tro- mechanics of many intertrochan- Reconstructive Surgeon, Department of chanter are described as having a teric fracture patterns. Other factors Orthopaedic Surgery, Rush University subtrochanteric component. The affecting the choice of fixation in- Medical Center, Chicago, IL. Dr. Egol is intertrochanteric region has an clude preexisting hip symptoms, the Chief of Fracture Service, Department of abundant blood supply, which presence of osteoarthritis, bone qual- Orthopaedic Surgery, NYU–Hospital for makes fractures in this area much ity, degree of comminution, and the Joint Diseases, New York, NY. Dr. less susceptible to osteonecrosis and patient’s medical condition. Zuckerman is Professor and Chairman, nonunion than are femoral neck Most of the classification systems Department of Orthopaedic Surgery, fractures. Fractures just proximal to for intertrochanteric fractures have NYU–Hospital for Joint Diseases. the intertrochanteric line, so-called poor reliability and reproducibility. Reprint requests: Dr. Zuckerman, basicervical fractures, are at greater A simplified system to aid in evalu- Department of Orthopaedic Surgery, risk for osteonecrosis (secondary to ating treatment algorithms when as- NYU–Hospital for Joint Diseases, 301 possibly being intracapsular) and sessing the literature is based on East 17th Street, New York, NY 10003. malunion (as a result of head rota- fracture stability, which is related to tion during implant insertion). How- the condition of the posteromedial J Am Acad Orthop Surg 2008;16:665- ever, they may be treated with the cortex. Fractures are considered sta- 673 same implants that are used for ble in the absence of a comminuted Copyright 2008 by the American intertrochanteric fractures. posteromedial cortex, reverse obliq- Academy of Orthopaedic Surgeons. Internal fixation of intertrochan- uity, and subtrochanteric extension teric fractures is the mainstay of (Figure 1). Volume 16, Number 11, November 2008 665 Surgical Management of Hip Fractures: An Evidence-based Review of the Literature. II: Intertrochanteric Fractures Figure 1 There is a paucity of level I evidence concerning whether nonsurgical treatment can provide a compa- rable outcome to that of surgical fixation for intertrochanteric hip fractures (Table 2). In 1989, Hornby et al2 performed a randomized prospective study comparing nonsurgical treatment (ie, traction) with a sliding hip screw (SHS) in 106 patients with intertrochanteric hip fracture. Complications were low in both groups, with no significant difference in 6-month mortality, pain, leg swelling, or pressure sores. Ana- tomic reduction was achieved more commonly with surgical treatment, and these patients had shorter hospital stays. Patients treated with traction had greater loss of independence at 6-month follow-up. The authors recommended surgical treatment for Intertrochanteric hip fracture. A, Standard oblique fracture (type I). B, Reverse medically stable patients. oblique fracture (type II). A 1981 prospective (level II) trial of 150 patients compared nonsurgical treatment (ie, skeletal traction The literature regarding intertro- and highest-level studies related to with a tibial pin) with surgical treat- chanteric fractures points to the dif- the treatment of intertrochanteric hip ment (eg, medial displacement os- ficulty in applying evidence-based fracture. Although level IV case stud- teotomy, valgus osteotomy).3 The treatment algorithms. The current ies contribute general recommenda- authors concluded that excellent re- evidence is conflicting and does not tions for the management of these sults were feasible with traction always support the treatment mo- fractures, we have focused on level I, alone provided that a high standard dalities that are widely used in prac- II, and III studies. of nursing care was maintained. tice. Techniques and implants con- Careful attention to bedside physical therapy, respiratory care, deep vein tinue to be modified, making the Nonsurgical Versus thrombosis prophylaxis, and preven- older literature less relevant to cur- Surgical Treatment rent practice. Varying fracture pat- tion of ulcers were vital to satisfac- terns may not be distinguished in Nonsurgical treatment of intertro- tory outcomes in nonsurgically clinical studies. The ability to make chanteric hip fractures is usually re- treated patients. absolute recommendations based on served for patients with comorbidi- A 2003 retrospective level III study clear evidence is limited by these ties that place these patients at reviewed a population database to problems. unacceptable risk from anesthesia, compare mortality rates in patients The Centre for Evidence-Based the surgical procedure, or both. Mor- with severe comorbidities who were Medicine created criteria for assign- tality from surgical treatment typi- treated either nonsurgically or surgi- ing levels of evidence (Table 1). We cally results from cardiopulmonary cally for intertrochanteric hip frac- performed a thorough literature re- complications, thromboembolism, ture.4 The 30-day mortality rate was view to determine the most pertinent and sepsis.1 lower in patients treated surgically. Dr. Egol or a member of his immediate family has participated in a speakers bureau or given paid presentations for Biomet; is an unpaid consultant for Biomet; has received research or institutional support from Biomet, Smith & Nephew, Stryker, and Synthes; and holds stock or stock options in Johnson & Johnson. Dr. Zuckerman or a member of his immediate family is affiliated with Neostem and Starmed as a board member, owner, officer, or committee member; has received royalties from Exactech; and has received research or institutional support from Exactech and Stryker. None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Kaplan, Dr. Miyamoto, and Dr. Levine. 666 Journal of the American Academy of Orthopaedic Surgeons Kevin Kaplan, MD, et al Table 1 Levels of Evidence for Primary Research Question* Type of Study Prognostic Studies— Investigating the Economic and Decision Therapeutic Studies— effect of a patient Diagnostic Studies— Analyses—Developing Investigating the results characteristic on the Investigating a an economic or Level of treatment outcome of disease diagnostic test decision model I High-quality RCT with High-quality prospective Testing of previously Sensible costs and statistically significant study§ (all patients were developed diagnostic alternatives; values difference or no enrolled at the same criteria on consecutive obtained from many statistically significant point in their disease patients (with universally studies; with difference but narrow with ≥80% follow-up of applied reference “gold multiway sensitivity confidence intervals enrolled patients) standard”) analyses Systematic review† of Systematic review† of Systematic review† of Systematic review† of level I RCTs (and level I studies level I studies level I studies study results were homogeneous‡) II Lesser quality RCT (eg, Retrospective# study Development of diagnostic Sensible costs and <80% follow-up, no Untreated controls criteria on consecutive alternatives; values blinding, or improper from an RCT patients (with universally obtained from limited randomization) Lesser quality prospective applied reference “gold studies; with Prospective§ study (eg, patients standard”) multiway sensitivity comparative study¶ enrolled at different Systematic review† of analyses Systematic review† of points in their disease or level II studies Systematic review† of level II studies or level <80% follow-up) level II studies I studies with Systematic review† of inconsistent results level II studies III Case-control study** Case-control study** Study of nonconsecutive Analyses based on Retrospective# patients (without limited alternatives comparative study¶ consistently applied and costs; and poor Systematic review† of reference “gold standard”) estimates level III studies Systematic review† of Systematic review†

Load more