Unstable Intertrochanteric Femur Fractures: Is There a Consensus on Definition and Treatment in Germany?
- 950 Downloads
Extramedullary and intramedullary implants have improved in recent years, although consensus is lacking concerning the definition and classification of unstable intertrochanteric fractures, with uncertainties regarding treatment.
We conducted a national survey of practicing chairpersons of German institutions to determine current perspectives and perceptions of practice in the diagnosis, management, and surgical treatment of unstable intertrochanteric fractures.
Between January and February 2010, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 26-question web-based survey regarding three broad domains: fracture classification and instability criteria, implants and surgical treatment algorithms, and timing of operations. Response rate was 42%.
There was a clear preference for use of the AO/OTA fracture classification with geographic variations. Absence of medial support was considered the main criterion for fracture instability (84%), whereas a broken lateral wall and detached greater trochanter were considered by 4% and 5% of the respondents, respectively, to determine instability. Two percent routinely fixed unstable intertrochanteric fractures with extramedullary devices. Ninety-eight percent of German hospitals reportedly perform surgery within 24 hours after admission. Time to surgery was dependent on hospital level, with more direct surgeries in Level I hospitals.
Despite varying opinions in the literature in recent years, we found some instability criteria (lateral wall breach, a detached greater trochanter) played a minor role in defining an unstable intertrochanteric fracture pattern. Despite recent meta-analyses suggesting clinical equivalence of intra- and extramedullary implants, few respondents routinely treat unstable intertrochanteric fractures with extramedullary plates. Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures.
Level of Evidence
Level V, expert opinion. See the Instructions for Authors for a complete description of levels of evidence.
- 1.Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. Leitlinien der Deutschen Gesellschaft für Unfallchirurgie: Pertrochantaere Oberschenkelfraktur. Available at: http://www.awmf.org/uploads/tx_szleitlinien/012-002l_S2_Pertrochantaere_Oberschenkelfraktur_2008_01.pdf. Accessed January 15, 2013.
- 3.Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long Gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010;92:792–798.PubMedCrossRefGoogle Scholar
- 6.Bonnevialle P, Saragaglia D, Ehlinger M, Tonetti J, Maisse N, Adam P, Le Gall C; French Hip and Knee Society (SFHG); Trauma Surgery Academy (GETRAUM). Trochanteric locking nail versus arthroplasty in unstable intertrochanteric fracture in patients aged over 75 years. Orthop Traumatol Surg Res. 2011;97(6 suppl):S95–S100.Google Scholar
- 8.Committee on Trauma of the American College of Surgeons. Resource for Optimal Care of the Injured Patient 1999. Chicago, IL: American College of Surgeons; 2000.Google Scholar
- 9.Deutsches Krankenhaus Adressbuch 2009. Freiburg, Germany: DKA/Rombach Gmbh + Co; 2008.Google Scholar
- 11.Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br. 1949;31:190–203.Google Scholar
- 12.Feinstein AR. The theory of evaluation of sensibility. In: Clinimetrics. New Haven, CT: Yale University Press; 1987:141–166.Google Scholar
- 22.Knobe M, Gradl G, Maier KJ, Drescher W, Jansen-Troy A, Prescher A, Knechtel T, Antony P, Pape HC. Rotationally Stable Screw-Anchor versus Sliding Hip Screw Plate Systems in Stable Trochanteric Femur Fractures: A Biomechanical Evaluation. J Orthop Trauma. 2012 October 30 [Epub ahead of print].Google Scholar
- 30.Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S1–S133.PubMedCrossRefGoogle Scholar
- 35.Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010;9:CD000093.Google Scholar
- 39.Schmidt-Rohlfing B, Heussen N, Knobe M, Pfeifer R, Kaneshige JR, Pape HC. Re-operation rate after internal fixation of intertrochanteric femur fractures with the Percutaneous Compression Plate (PCCP): what are the risk factors? J Orthop Trauma. 2012 September 3 [Epub ahead of print].Google Scholar
- 41.Singleton RA, Straits BC, Straits MM. Approaches to Social Research. New York, NY: Oxford University Press; 1993.Google Scholar