Evaluation and Management of an Unstable

Special Case Report Series JOT CASE REPORTS

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Belgian Orthopaedic Trauma Association Canadian Orthopaedic Trauma Society Foundation for Orthopedic Trauma International Society for Fracture Repair The Japanese Society for Fracture Repair Evaluation and Management of an Unstable Intertrochanteric Fracture of the Femur: A Case Report Harish Kempegowda, MS, Akhil Tawari, MS, Michael Suk, MD, JD, MPH, FACS, and Daniel S. Horwitz, MD

fixation include hardware failure, nonunion, malunion, limb length Unstable intertrochanteric fracture of the femur is one of the most discrepancy, and diminished abductor lever strength.4 The increase commonly encountered orthopaedic injuries in the United States. in the incidence of complications has led to an extension of the A 63-year-old female sustained a highly unstable intertrochanteric definition of instability to include lateral wall blow out, greater fracture of the femur (OTA 31-A 3.3) and she was treated with trochanteric fracture, and osteoporosis.4,5 The preoperative identi- a long cephalomedullary nail. Four months later, a solid union fication of an unstable pattern is of utmost importance in reducing occurred at the fracture site with minimal limb length discrepancy complications. and the patient regained her pre-operative functional status. This Many fixation methods have been described to treat IT fractures, case report highlights the important points which must be of which the sliding hip screw and intramedullary devices (IMDs) considered in the treatment of an unstable intertrochanteric have stood the test of time. Biomechanical and clinical studies fracture with emphasis on preoperative evaluation, intraoperative show a clear advantage of IMDs over sliding hip screws in fixation management and post-operative protocol for a good outcome. of unstable fracture patterns.6,7 The evolution of nailing systems began with the first-generation gamma nail (Stryker, Mahwah, NJ) Key Words: unstable intertrochanteric fractures, cephalomedul- in the 1980s and has progressed to current fourth-generation lary nail nails.8,9

INTRODUCTION CLINICAL SCENARIO Unstable intertrochanteric (IT) fractures are relatively common A 63-year-old woman presented to the emergency department injuries among the geriatric population.1,2 As per the most com- with 10/10 pain in her left hip subsequent to fall at home. She had monly used Evans classification, loss of posteromedial integrity, IT a known diagnosis of osteoporosis for which she was on regular fractures with subtrochanteric extension, and the reverse oblique calcium, vitamin D supplements, and once yearly bisphosphonates. pattern are considered unstable.2,3 The complications after internal She was nonhypertensive, nonsmoker, and denied any other significant past medical or surgical illnesses. A focused clinical Accepted for publication June 2, 2015. examination revealed a left lower extremity in extreme external rotation, shortening, and generalized hip pain. From the Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA. D. S. Horwitz is a consultant and receives royalties from Biomet. The DIAGNOSTIC ASSESSMENT remaining authors report no conflict of interest. Plain radiographs anteroposterior (AP) view and cross-table Reprints: Daniel S. Horwitz, MD, Department of Orthopaedic Surgery, lateral view of the left hip, traction-internal rotation view, and Geisinger Medical Center, 100 N Academy Avenue, Danville, PA 17822- a computed tomography scan (CT) scan with 3D reconstruction 2130 (e-mail: [email protected]). were obtained. These revealed a loss of posteromedial continuity, The views and opinions expressed in this case report are those of the subtrochanteric extension, greater trochanteric comminution, and authors and do not necessarily reflect the views of the editors of Journal a fracture line extending up to the femoral neck, making this injury of Orthopaedic Trauma or Biomet. highly unstable (Figs. 1A–E).

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FIGURE 1. AP (A), lateral (B), traction- internal rotation (C), radiographic images and CT scan with 3D reconstruction (D and E) of the left hip show an IT fracture femur with the comminution of greater trochanter, subtrochanteric extension, and a separate anteromedial and posteromedial frag- ment.

TREATMENT avoid damage to abductors and to promote valgus reduction.11 The Considering the highly unstable nature of the fracture, the entry wire position was confirmed on AP and true lateral fluoro- authors chose to proceed with long intramedullary nailing. Closed scopic views and advanced into the medullary canal. After reduction was attempted with longitudinal traction followed by advancement of the wire, the position was confirmed on AP and internal rotation but was unable to correct posterior sag and true lateral fluoroscopic views. The entry reamer was then used to medialization of the femoral neck. Based on this, the decision gain access to the medullary canal, and the entry wire was removed. was made to perform an open reduction.10 The posterior sag was The reduction was maintained with the reduction forceps through- corrected using a posteriorly placed Cobb elevator, and the medi- out the procedure, and a ball-tipped guide wire was introduced into alization of the femoral neck was corrected using a bone hook. the proximal femoral canal and advanced down the distal femur. Its The reduction thus obtained was maintained by a coaxial clamp position was confirmed distally on AP and lateral views. The fem- (Fig. 2A). The intraoperative fluoroscopic images revealed an oral canal was sequentially reamed up to 11 mm, and a 9 3 360 mm acceptable alignment of the femoral head and neck with the shaft nail was then placed over the guide wire and seated distally by without any varus or medialization of the femoral neck. An incision hand. At this point, central–central position of a compression screw was made proximal to the tip of the greater trochanter, and an entry guide wire in the femoral head was obtained, screw length was wire was placed 1 mm medial to the tip of greater trochanter to determined, a step drill was used over the guide wire, and an

FIGURE 2. Note the correction of medialization of the femoral neck after the placement of a bone hook, and the reduction was held with a coaxial clamp (A). The ball-spiked pusher was placed laterally to impact the fracture (B). e2 www.jorthotrauma.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Unstable Intertrochanteric Fracture of the Femur

FIGURE 3. AP (A) and lateral (B) fluoroscopic images after the placement of nail show an acceptable alignment, minimal fracture gap, and insignificant medialization. appropriate sized compression screw was placed. Because of con- DISCUSSION cern for possible rotational instability, the guide wire for a derota- Intertrochanteric fractures are considered unstable when any of tion screw was placed to provide provisional stability during the following features are present: posteromedial discontinuity, compression screw advancement. The compression screw was subtrochanteric extension, reverse oblique pattern, greater trochan- rotationally locked with a set screw device but was allowed to ter comminution, and lateral wall insufficiency. In addition, collapse. A ball-spiked pusher was placed laterally to impact the osteoporosis leads to further instability.1,2,4,5 IT fractures occur in fracture (Fig. 2B). At this point, traction was released and com- metaphyseal regions, so healing is rarely a major problem, but late pression was achieved, which further increased rotational complication including malunion, shortening of the limb, and stability. The construct then underwent live fluoroscopic external rotation deformity can significantly affect postsurgical evaluation on the lateral view, and rotational stability was con- ambulation.4 firmed. Based on this, it was believed that the compression In this patient, the initial plain radiographs revealed a peritro- screw alone would provide adequate rotational stability and chanteric fracture, but the specifics of the injury pattern were a derotation screw was not required. Finally, a single distal difficult to assess (Figs. 1A, B). The addition of a traction view and interlock screw was placed. The intraoperative images after CT scan with 3D reconstruction was of great value in evaluating the placement of the nail showed excellent neck shaft this injury (Figs. 1C, D). CT scan is not advisable in each case, but alignment, minimal fracture gap, and no significant medializa- we recommend only if there is a complex fracture where specifics of tion of the femur neck (Figs. 3A, B). injury pattern cannot be defined even on a traction view. Ideal preoperative planning begins with classification, and as per the OTA classification, this case belongs to the unstable IT 31-A3.3 FOLLOW-UP AND OUTCOMES group.12 To address the complexity and instability in this injury, Postoperatively, the patient was made weight bearing as a long cephalomedullary nail was chosen. A major key to success in tolerated. Radiographs obtained at 6 weeks showed further this case was the intraoperative reduction of the fracture as impaction at the fracture site as anticipated. The patient was described earlier and utilization of the dynamic property of the encouraged to continue to mobilize and began outpatient physical implant that led to solid union. In this case, further collapse at the therapy stressing aerobic conditioning, gait training, and balance fracture site could be seen at 6 weeks, as was anticipated, and exercises, as the fracture showed excellent evidence of healing and complete healing was evident at the end of 4 months (Figs. 4A, B). well-positioned hardware. At 1 year postoperatively, there Historically, displacement osteotomies were considered as was minimal limb length discrepancy without any obvious standard treatment for unstable IT fractures; however, later deformity, and radiographs showed overall excellent alignment studies showed no advantage in comparison with anatomic with a well-healed fracture (Figs. 4A, B). fixation.13,14 To restore the medial buttress, extra screws or

FIGURE 4. One-year postoperative radiographic images of AP (A) and lateral view (B) showing excellent alignment and well-healed fracture.

Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Kempegowda et al cerclage wire would be necessary if a sliding screw was the 5. Kim WY, Han CH, Park JI, et al. Failure of intertrochanteric fracture implant of choice, but this is associated with significant soft tissue fixation with a dynamic hip screw in relation to pre-operative fracture – fi 15 stability and osteoporosis. Int Orthopaedics. 2001;25:360 362. stripping and only a 17% increase in the xation strength. The 6. Curtis MJ, Jinnah RH, Wilson V, et al. Proximal femoral fractures: a bio- greater trochanter constitutes the lever arm of the abductor mech- mechanical study to compare intramedullary and extramedullary fixation. anism, so near anatomic fixation is necessary for normal hip func- Injury. 1994;25:99–104. tion. In this case, although the greater trochanter appeared to be 7. Al-yassari G, Langstaff RJ, Jones JW, et al. The AO/ASIF proximal comminuted, it was believed that the abductor mechanism was femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury. 2002;33:395–399. intact. If components of the greater trochanter are widely dis- 8. Albareda J, Laderiga A, Palanca D, et al. Complications and technical placed, we would advise open reduction and suture fixation of problems with the gamma nail. Int Orthop. 1996;20:47–50. fragments to whatever implant is chosen. 9. Yaozeng X, Dechun G, Huilin Y, et al. Comparative study trochanteric Thecost-effectiveanalysis,biomechanical studies, and clin- fracture treated with the proximal femoral nail anti-rotation and the third – ical outcomes suggest that IMDs are better devices for unstable generation gamma nail. Injury. 2010;41:1234 1238. 16 10. Afsari A, Liporace F, Lindvall E, et al. Clamp-assisted reduction of high sub- IT fractures. The earlier generation nails were associated with trochanteric fractures of the femur. J Bone Joint Surg Am. 2009;91:1913–1918. multiple problems including shaft fracture at the end of nail, 11. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccen- screw cutout, and femoral neck fracture after hardware removal.8 tric starting point for trochanteric intramedullary femoral nailing. J Orthop – The newer generation nails are associated with significantly Trauma. 2005;19:681 686. 12. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification fewer complications; however, some issues such as femoral neck compendium—2007: Orthopaedic Trauma Association classification, database 9 fracture after implant removal continue to exist. The advantage and outcomes committee. J Orthop Trauma. 2007;21(10 suppl l):S1–S133. of an IMD also includes earlier mobilization and less limb short- 13. Dimon JH, Hughston JC. Unstable intertrochanteric fractures of the hip. J ening, both of which may enhance the patient’s general well- Bone Joint Surg Am. 1967;49:440–450. 17 14. Desjardins AL, Roy A, Paimont G, et al. Unstable intertrochanteric frac- being. ture of the femur: a prospective randomized study comparing anatomical In conclusion, preoperative identification of the unstable reduction and medial displacement osteotomy. J Bone Joint Surg Br. 1993; fracture pattern with proper radiologic investigations, selection of 75:445–447. the most suitable implant based on fracture pattern, achieving and 15. Apel DM, Patwardhan A, Pinzur MS, et al. Axial loading studies of unstable intertrochanteric fractures of the femur. Clin Orthop Relat Res. maintaining reduction during nail placement, and early postoper- – ’ 1989;246:156 164. ative mobilization will maximizes the patient s recovery in an 16. Swart E, Makhni EC, Macaulay W, et al. Cost-effectiveness analysis of unstable IT fracture. fixation options for intertrochanteric hip fractures. J Bone Joint Surg Am. 2014;96:1612–1620. 17. Gadegone WM, Salphale YS. “Proximal femoral nail—an analysis of 100 REFERENCES cases of proximal femoral fractures with an average follow up of 1 year”. Int Orthop. 2007;31:403–408. 1. Koval KJ, Zuckerman JD. Intertrochanteric fractures. In: Bucholz RW, Heckman JD, eds. Fractures in Adults. 5th ed Philadelphia, PA: Lippincott Williams and Wilkins; 2001:1635–1663. 2. Evans EM. The treatment of trochanteric fractures of the femur. J Bone Read the rest of the JOT Case Reports online on www. Joint Surg Br. 1949;31B:190–203. jorthotrauma.com. It’s the Grand Rounds series from the Journal 3. Jensen JS. Classification of trochanteric fractures. Acta Orthop Scand. of Orthopaedic Trauma, the official journal of the Orthopaedic 1980;51:803–810. 4. Im GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. Trauma Association. J Orthop Trauma. 2005;19:5–9.