Intertrochanteric femur fractures: a current concepts review

Abstract

Intertrochanteric fractures are common injuries around the hip, especially among the elderly. With the rising incidence of these injuries, they are expected to double by 2050. Incidence rates are higher in females than males and in white patients than black African patients. Osteoporosis weakens the local trochanteric anatomic support leading to an increased susceptibility to fractures. Disruption of the posteromedial calcar region results in fracture instability. Optimal lag screw position and fracture reduction are significant determinants for postoperative outcomes. The tip apex distance and reduction criteria determine lag screw cut-out risk and fracture reduction quality, respectively. A calcar-referenced tip apex distance is comparable if not better than the tip apex distance in predicting cut-out risk. Optimal reduction is in slight valgus, a positive medial cortex apposition and smooth anterior cortex apposition. High mortality rates are observed with non-surgical treatment. Surgical management is therefore the gold standard for intertrochanteric fractures. Treatment options are categorised into extramedullary fixation, intramedullary fixation and proximal femur replacement. They include the dynamic hip screw (DHS), cephalomedullary nails (CMN) and arthroplasty. Although still in use, the proximal femur locking plate is falling out of favour due to high complication rates. Fracture stability and pattern influence the treatment choice. There is, however, a growing use of CMNs which has been attributed to surgical training background. Modification of older CMN designs has improved treatment outcomes. Systematic meta-analyses of randomised controlled trials (RCTs) do not show superiority of one treatment option over another; therefore, there is no consensus on the best treatment choice. The proximal femur nail antirotation (PFNA) has better outcomes compared to other fixation options with respect to intraoperative blood loss and Harris hip scores. As a group, CMNs have a better 120-day postoperative quality of life compared to the DHS. No significant difference in complications has been found between treatment options. In light of the anticipated increased incidence of intertrochanteric fracture, more work is needed in planning national resource allocation, devising preventative methods and improving clinical interventions in South Africa. Level of evidence: Level 5

Anteromedial Cortical Support in Reduction of Trochanteric Hip Fractures

“…The CRQC implements a 4-point scoring system, allowing for a detailed and methodical evaluation of the reduction quality in both anteroposterior and lateral views. Meanwhile, the BRQC uses a general description, which does not differentiate between the conditions of poor alignment only in anteroposterior views, poor alignment in only lateral views, and poor alignment in both anteroposterior and lateral views, as these conditions are all grouped under the term “poor alignment.” 22,29,59 Moreover, in the displacement description, the CRQC adopts expressions such as “1 or 0.5 cortical thickness.” This not only provides practical means for surgeons to conduct evaluation visually, eliminating the need for measurement tools, but also underscores the buttress function of the anteromedial cortex in maintaining stability 22,59,60 . In contrast, the BRQC uses a 4-mm benchmark to describe displacement, requiring the use of measuring instruments for accurate appraisal and not engaging the surgeon’s attention toward the anteromedial cortex 55 .…”

“…The CRQC brought an improvement by incorporating the AMCS concept into the requirements for displacement, addressing a previous omission where the importance of anteromedial reduction was not taken into account 22,55,60 . In the BRQC, a good displacement on the anteroposterior view is defined as a displacement of the fracture fragment of <4 mm.…”