Avoiding varus malreduction during cephalomedullary nailing of intertrochanteric hip fractures

Abstract

We describe a technique for preventing varus malreduction of intertrochanteric hip fractures during fixation with a cephalomedullary nail. When the entry reamer guidewire is positioned in the fracture line, passage of the entry reamer may simply push the proximal fragment medially and the distal fragment laterally rather than ream the accurate entry path. Subsequent nail insertion will result in a varus deformity of the proximal femur. The simple technique described in this report uses a brief period of over-distraction to wedge the entry reamer guidewire against the lateral edge of the proximal fragment, permitting the reamer to cut a correct path in the lateral edge of the proximal fragment. Creation of a proper entry path is essential to maintain anatomic reduction during cephalomedullary nailing of intertrochanteric hip fractures.

Wedge effect following intramedullary hip screw fixation of intertrochanteric proximal femur fracture

“…He described a technique utilizing over-distraction of the fracture fragments to force the guidewire against the lateral femoral neck cortex to ensure adequate reaming [15]. However, there was no discussion regarding outcomes or results utilizing this technique.…”

Contemporary Management of Subtrochanteric Fractures

“…Multiple tools are available to assist the surgeon in reduction, such as ball spike pushers, femoral distractors, terminally threaded pins, bone hooks, various tissue elevators, poller screws, radiolucent external reduction tools, and intramedullary instruments. [74][75][76][77][78][79][80] Although intramedullary fixation is viewed as an indirect reduction technique, open nailing can also be performed to achieve a more anatomic reduction. Use of cerclage cables to assist in reduction has been evaluated for its efficacy and risks.…”

Conversion to total hip arthroplasty after failed proximal femoral nail antirotations or dynamic hip screw fixations for stable intertrochanteric femur fractures: a retrospective study with a minimum follow-up of 3 years

“…These fractures are well known to cause significant physical and functional impairment for patients and require substantial financial resources for both perioperative and rehabilitative care [3]. Proximal femoral nail anti-rotation (PFNA) and dynamic hip screw (DHS) fixation are accepted treatment options that are currently widely used as the primary treatment for stable intertrochanteric fractures (AO/OTA Type 3.1A1) [4, 5]. There is generally agreement that failed PFNA or DHS fixations of intertrochanteric fractures should be treated with a conversion to total hip arthroplasty (CTHA) whenever possible [3].…”

“…However, it has been unclear whether there are differences in the success rates for converting PFNA or DHS to a THA [3]. On the other hand, numerous studies have been published regarding comparisons of PFNA and DHS for the fixation of intertrochanteric fractures in active elderly patients [4–6]. Thus far, there has been no clear conclusion regarding the superiority of one of the approaches over the other.…”