Unstable Intertrochanteric Fractures

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Unstable Comminuted Intertrochanteric fractures remain a difficult unsolved fracture for the elderly.

Standard treatment with dynamic hip screw often resulting in hardware cut out and healing with varus malunion.

Patient have to be non weight bearing for a prolonged period of time and the limb is often healed shortened and externally rotated.

Given that patients with hip fractures have shortened life span, the non weight bearing period may constitute a significant portion of the patient's remaining life span

Unstable intertrochanteric fracture remain an unsolved hip fracture for the elderly.

My partner in Lubbock, TX Dr. Gurdev Gill is a highly skilled orthopedic surgeon who has been using hemiarthroplasty for unstable intertrochanteric fractures for many years prior. I was very impressed with his results and the quick recovery of his patients. I then decided to try his technique. Most of the surgical technique described originate from him and I like to pay tribute to his contributions.

A proposed solution for this very difficult hip fracture in the elderly.

We wrote a paper in 2001 on a possible solution to this very difficult hip fracture using cemented bipolar hemiarthroplasty.

An abstract of our paper Cemented Hemiarthroplasties for Elderly Patients With Intertrochanteric Fractures is given here. This paper has as of late 2021 been cited 540. Many of the citations in recent years originate from China and South Korea. I guess they do a lot of hemiarthroplasty for unstable intertrochanteric fractures in China and South Korea.

Even though we demonstrated in this paper that the surgical time, blood loss and complications were less than the then standard treatment with telescoping hip screw we initially had difficulty getting this paper published and it was even criticised as a "dangerous" approach as most reviewers were unfamiliar with this surgical approach and did not appreciate the detail that make this approach a success.

Calcar replacement prosthesis has been recommended for unstable intertrochanteric fractures especially in Europe but is has not been generally accepted because of the more extensive surgery required and less than certain result.

Positioning and Surgical Approach

The patient is positioned in the supine position with the affected hip slightly elevated on a sandbag.

Our approach is strictly an anterior approach but with a modified skin incision. The modified skin incision starts at the anterior superior iliac spine and curve medially towards the mid inguinal line and then extending straight distally for another 6 inches.

The anterior approach with this modified skin incision has the the following advantage:

  1. The anterior approach with the patient in the supine position allows full visualization of the fractured anterior cortex of the intertrochanteric area which unlike the posterior cortex is not comminuted

  2. The anterior approach with the skin incision starting slightly posteriorly allows for easy access to the greater trochanter and easy reaming of the femoral canal with minimal obstruction by a straight skin incision.

  3. With the patient in the supine position and an anterior approach the anterior cortex of the intertrochanteric fracture can be fully visualized.

  4. The slightly posterior starting position of the skin incision reduces the obstruction of the skin incision during femoral reaming as compared to a straight mid inguinal incision in the classical anterior hip approach.

Modified skin incision for anterior approach to the hip.

Modified skin incision for anterior approach to the hip.

Key steps for success are here:

  1. Anterior Approach to the hip

  2. Modified skin incision to allow canal access during reaming of the femoral canal

  3. The anterior fracture line in the anterior intertrochanteric region can be anatomically reduced with ease

  4. Safely cerclage the fracture fragments with AO wire wire passer.

  5. Peel back anterior 3mm of the abductor attachment at the greater trochanter for easy reaming of femoral canal

  6. Mix simplex bone cement at the same time as you start preparing the femoral canal

Reduction of the anterior fracture line

The the anterior aspect of the proximal femur is expose by placing the tip of the hohmann retractor in the posterior aspect proximal femur and levering the sartorius and tensor fascia lata posteriorly.

The anterior fracture line on the anterior intertrochanteric region is fully exposed. Rotating the limb and then depressing the proximal thigh posteriorly, the fracture line in the fracture line in the anterior cortex is anatomically reduced with ease.

Once the fracture is reduced, the intertrochanteric fracture, the calcar (less trochanter) and the greater trochanter are all wired in place using an AO wire passer to avoid injury to the sciatic nerve posteriorly.

AO Cerclage Wire Passer

Putting in the femoral prosthesis

It may not be appropriate to use a cementless femoral stem for two reasons.

  1. It requires a period of partial weight bearing of up 6 weeks after surgery.

  2. The femoral canal in the elderly are generally wide and osteoporotic. Cementless stem is not recommend as thigh pain and stress shielding may be significant.

To reduce the surgical time and trauma hemiarthroplasty was chosen as no preparation of the acetabulum is needed since most fractured hip the acetabulum is prestine. We chose bipolar hemiarthroplasty for the possibility of less hip pain and less likelihood of acetabular erosion. It is also possible to convert the bipolar hemiarthroplasey to a total hip replacement in the future for hip pain.

How to prepare the femoral canal

The general misconception is that the gluteal muscle is fully attached to the greater trochanter. The fact is the abductor muscle on only attached below the trochanteric line (rough line). There is a bursa interposed between the upper half the greater trochanter and abductor muscle. This is indeed already noted in Gray's anatomy 1858 original edition on page 148. Access to the femoral canal for reaming is accomplished by peeling back the anterior 3 mm of the abductor attachment. Damage to the abductor muscle during femoral reaming is thus avoiding. The minor abductor detachment can be easily and securely reattached to the relatively soft cancellous bone of the greater trochanter with #1 or #2 sutures on a sharp needle.

Generally Simplex bone cement takes about 12 minutes to set from the time it is mixed. The dough time is about 10 minutes for cement mixed normally and about 8 minutes when mixed in vacuum.

To save time as soon as the preparation of the femoral canal is started we start mixing the bone cement. This cuts the operating time by 10 minutes. From our experience we had never experience the bone cement setting prematurely.

Patient is allowed full weight bearing immediately postop.

Follow up Xray is taken at 8 or 12 weeks and by then exuberant callous formation can be seen in the posterior aspect of the intertrochanteric area where bone debris and fracture fragments were left undisturbed with an anterior approach.

Appreciate your feedback and comments. Please write to me at casey@aceblaster.com or Whatsapp me at +65 9673 4702