Outcome of intramedullary nailing treatment for intertrochanteric femoral fractures

Clifford B Jones,Justin D Khoriaty,Debra L Sietsema,Martin F Hoffmann

doi:10.1186/s13018-019-1431-3

Abstract

IntroductionThe OTA/AO type 31 A3 intertrochanteric fracture has a transverse or reverse oblique fracture at the lesser trochanteric level, which accentuates the varus compressive stress in the region of the fracture and the implant. Intramedullary fixation using different types of nails is commonly preferred. The purpose of this study is to evaluate intertrochanteric femoral fractures with intramedullary nail treatment in regard to surgical procedure, complications, and clinical outcomes.MethodsFrom one level 1 trauma center, 216 consecutive adult intertrochanteric femoral fractures (OTA/AO type 31 A3) were retrospectively identified with intramedullary nail fixation from 2004 through 2013. Of these, 193 patients (58.5% female) met the inclusion criteria. The average age was 70 years (range 19–96 years).ResultsCephalomedullary nails were utilized in 176 and reconstruction nails in 17 patients. After the index procedure, 86% healed uneventfully. Nonunion development was observed in 6% and 5% had an unscheduled reoperation due to implant or fixation failure. Active smoking was reported in 16.6%. Current smokers had an increased nonunion risk compared to those who do not currently smoke (15.6% vs. 4.3%; p = 0.016). The femoral neck angle averaged 128.0° ± 5°. Fixation failure occurred in 11.1% of patients with a neck-shaft-angle < 125° compared to 2.6% (4/155) of patients with a neck-shaft angle ≥125° (p = 0.021). Patients treated with a reconstruction nail required a second surgical intervention in 23.5%, which was no different compared to 25.0% in the cephalomedullary group (p = 0.893). In the cephalomedullary group, 4.5% developed a nonunion compared to 23.5% in the reconstruction group (p = 0.002). Painful hardware led to hardware removal in 8.8%. All of them were treated with a cephalomedullary device (p = 0.180). During the last office visit, two-thirds of the patients reported no or only mild pain but most patients had reduced hip range of motion.ConclusionIntramedullary nailing is a reliable surgical technique when performed with adequate reduction. Varus reduction with a neck-shaft angle < 125° resulted in an increase in fixation failures. Patient and implant factors affected nonunion formation. Smoking increased nonunion formation. Utilization of a cephalomedullary device reduced the nonunion rate, but had higher rates of painful prominent hardware compared to reconstruction nailing.

Highlights

The Orthopedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 31 A3 intertrochanteric fracture has a transverse or reverse oblique fracture at the lesser trochanteric level, which accentuates the varus compressive stress in the region of the fracture and the implant
Reduction, fixation, and maintenance of alignment until fracture healing are potential difficulties leading to high incidences of fixation failures with extramedullary devices [16], which are usually preferred for extracapsular hip fractures [17]
Despite the superiority of the sliding hip screw compared to intramedullary nails for the treatment of extracapsular femur fractures [17], there is a permanent confusion regarding the best treatment for fractures of the trochanteric region [13, 20] with an increasing body of evidence suggesting that pertrochanteric fractures with subtrochanteric extension and intertrochanteric fractures are best treated with the use of an intramedullary long nail [5, 15, 25, 26]

Summary

Introduction

The OTA/AO type 31 A3 intertrochanteric fracture has a transverse or reverse oblique fracture at the lesser trochanteric level, which accentuates the varus compressive stress in the region of the fracture and the implant. According to the Orthopedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) pertrochanteric fractures run obliquely from the greater trochanter to the lesser trochanter (31 A1 and 31 A2) [10, 11]. This allows controlled impaction of the fracture site in compression hip screws and most intramedullary nailing systems [12]. Related to the stability aspect intramedullary nailing has become popular for the treatment of unstable intertrochanteric hip fractures (Fig. 2) [18, 19]

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