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Level IV Diagnostic. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Hip fractures are common and disabling injuries, usually managed surgically. The most common type outside the joint capsule are trochanteric fractures, usually fixed with either sliding hip screw or intramedullary nail. Data are available in the National Hip Fracture Database (NHFD) on early failure and other major complications, but late or subtler complications may escape recording. This study sought to quantify such problems after fixation performed at 3different sites and identify their predictors. Methods: Patients with a trochanteric fracture treated at 1 of 3 sites were identified from the NHFD over a 3-year period. Any with further, related episodes of care were identified, and reasons recorded, then age- and sex-matched with those with no such episodes. Data was collected on Arbeitsgemeinschaft für Osteosynthesefragen classification, tip-apex distance, American Society of Anesthesiologists (ASA) grade, Abbreviated Mental Test Score and pre-injury mobility. The cohorts were compared, and a binomial logistic regression model used to identify predictors of problems. Results: A total of 4010 patients were entered in the NHFD across 3 sites between January 2013 and December 2015. Of these, 1260 sustained trochanteric fractures and 57 (4.5%) subsequently experienced problems leading to re-presentation. The most common was failure of fixation, occurring in 22 patients (1.7%). The binomial logistic regression model explained 47.6% of the variance in incidence of postoperative problems with ASA grade and tip-apex distance being predictive. Discussion: The incidence of re-presentation with problems was around of 5%. A failure rate of less than 2% was seen, in keeping with existing data. This study has quantified the incidence of subtler postoperative problems and identified their predictors. The type of implant used was not amongst them and patients with both implants experienced problems. Fixation continues to yield imperfect results, but patient health and robust surgical technique remain important factors in a good outcome.

We read with interest the article by Tan et al. 1 and agree that the AO 23 B3 fracture may re-displace following attempted volar plate fixation. In our experience the fracture posing the greatest challenge is a distal exiting fracture line with a small volar lip fragment. 2 Traditional volar plate design provides a more proximal buttress on the volar calcar to avoid plate prominence at the watershed line. In addition the AO 23 C.2 and C.3 fractures with comminution of the articular surface or metaphyseal comminution with an axial fracture line separating the joint fragments from the main metaphyseal volar fragments also pose a risk of volar displacement. Traditionally we would have used additional sub-articular volar lag screws distal to the plate in the B3 fracture and dorsal plating for the C.2 and C.3 configurations. The lack of volar support may render the whole of the reduced construct to collapse at the proximal calcar fracture line necessitating the use of an additional extra-articular volar plate to provide a volar buttress. It is now our practice to use the AO volar rim plate for fixation of such fractures through a single volar approach. We have treated 24 cases using this approach without any cases or redisplacement. The drawback of this technique is the distal plate placement potentially causing flexor irritation, the risk of articular penetration necessitating the use of variable angle distal screw and the limited fixation options of the radial styloid in fractures with extreme comminution.

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