Principles and Evidence: The Optimal Treatment of Pertrochanteric Hip Fractures

Abstract

This randomized clinical trial highlights several important principles in the management of pertrochanteric and subtrochanteric proximal femoral fractures in the elderly. The authors compared intramedullary and extramedullary fixation for these fractures with respect to pain, function, complications, and radiographic parameters for up to one year. As was the case in previous studies1, the authors were unable to identify a significant difference in functional outcome, although a recent large trial did show a trend toward better recovery of mobility with intramedullary fixation2. In the present study, the authors found that patients treated with nailing had slightly less pain with mobility early on but not after hospital discharge. However, there were differences in the radiographic parameters and some technical issues and complications that bear closer scrutiny. The authors reported several cases of cutout of both the nail and the sliding hip screw. In figures included with the article, it appears that this happened without the medial bone fragment having been able to move along the sliding implant axis. It bears reminding that both intramedullary and extramedullary devices can be used in sliding mode to maintain contact across the fracture surface and thereby promote bone healing. When a rigid or locked implant is used, resorption at the fracture site results in stress concentration across small fracture gaps and the likelihood of implant failure is high. With pertrochanteric fractures, this usually involves implant cutout as bone collapses around a nonsliding …