Evolving concept in treatment of intertrochanteric fractures and development of internal fixation devices_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LI Jiantao , ZHANG Licheng ,  TANG Peifu

Department of Orthopaedics, Chinese PLA General Hospital, Beijing, 100853, P.R.China;

Corresponding author：

TANG Peifu, Email: pftang301@163.com

Keywords：

Intertrochanteric fracture; internal fixation device; treatment concept

DOI：

10.7507/1002-1892.201809076

Video：

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Objective To summarize the evolving concept in treatment of intertrochanteric fractures and the development of internal fixation devices. Methods Related literature concerning the implant devices to treat intertrochanteric fractures was reviewed and analyzed in terms of the biomechanical characteristics, clinical application, and complications. Results The treatment of intertrochanteric fractures has undergone an evolving concept from conservative treatment to surgical treatment. Surgery strategies include extramedullary fixation and intramedullary fixation. Intramedullary fixation has gradually become the main treatment of intertrochanteric fractures due to its minimally invasive and biomechanical advantages. However, the current intramedullary fixation system still can not reconstruct the medial cortical support of the proximal femur, which leads to some failures in the treatment of unstable fractures. Conclusion The development of internal fixation of intertrochanteric fractures is based on the deep understanding and biomechanical theory of intertrochanteric fractures in clinical practice. In the future, the updated design of internal fixation devices will depend on the treatment principle of reconstruction of medial support and secondary stabilization of intertrochanteric fractures, and finally the purpose of improving success rate and reducing postoperative complications of intertrochanteric fracture will achieved.

Citation： LI Jiantao, ZHANG Licheng, TANG Peifu. Evolving concept in treatment of intertrochanteric fractures and development of internal fixation devices. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(1): 1-7. doi: 10.7507/1002-1892.201809076 Copy

1.	Clawson DK. Intertrochanteric fracture of the hip. Am J Surg, 1957, 93(4): 580-587.
2.	Scott JF. Treatment of trochanteric fractures. J Bone Joint Surg (Br), 1951, 33-B(4): 508-512.
3.	Murray RC, Frew JF. Trochanteric fractures of the femur; a plea for conservative treatment. J Bone Joint Surg (Br), 1949, 31B(2): 204-219.
4.	Bong SC, Lau HK, Leong JC, et al. The treatment of unstable intertrochanteric fractures of the hip: a prospective trial of 150 cases. Injury, 1981, 13(2): 139-146.
5.	Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg (Br), 1949, 31-B(2): 190-203.
6.	Jewett EL. One-piece angle nail for trochanteric fractures. J Bone Joint Surg, 1941, 23(4): 803-810.
7.	Cleveland M, Bosworth DM, Thompson FR, et al. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg, 1959, 41-A: 1399-1408.
8.	Sarmiento A. Intertrochanteric fractures of the femur: 150-degree-angle nail-plate fixation and early rehabilitation: a preliminary report of 100 cases. J Bone Joint Surg, 1963, 45(4): 706-722.
9.	Dimon JH. Hughston JC. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg (Am), 1967, 49(3): 440-450.
10.	Wilson JH, Rubin BD, Helbig FE, et al. Treatment of interotrochanteric fractures with the Jewett nail: experience with 1,015 cases. Clin Orthop Relat Res, 1980, (148): 186-191.
11.	McLaughlin HL. An adjustable internal fixation element for the hip. Am J Surg, 1947, 73(2): 150-161.
12.	Foster JC. Trochanteric fractures of the femur treated by the Vitallium McLaughlin nail and plate. J Bone Joint Surg (Br), 1958, 40-B(4): 684-693.
13.	Sahlstrand T. The Richards compression and sliding hip screw system in the treatment of intertrochanteric fractures. Acta Orthopaedica Scandinavica, 1974, 45(2): 213-219.
14.	Jensen JS, Michaelsen M. Trochanteric femoral fractures treated with McLaughlin osteosynthesis. Acta Orthopaedica Scandinavica, 1975, 46(5): 795-803.
15.	Kolind-Øsrensen V. Comminuted intertrochanteric fracture of the femoral neck. Acta Orthopaedica Scandinavica, 1975, 46(4): 651-653.
16.	Jensen JS, Sonne-Holm S, Tøbndevold E. Unstable trochanteric fractures. A comparative analysis of four methods of internal fixation. Acta Orthopaedica Scandinavica, 1980, 51(6): 949-962.
17.	Dickson JA. The unsolved fracture; a protest against defeatism. J Bone Joint Surg (Am), 1953, 35-A(4): 805-822.
18.	Schumpelick W, Jantzen PM. A new principle in the operative treatment of trochanteric fractures of the femur. J Bone Joint Surg (Am), 1955, 37-A(4): 693-689.
19.	Pugh WL. A self-adjusting nail-plate for fractures about the hip joint. J Bone Joint Surg (Am), 1955, 37-A(5): 1085-1093.
20.	Clawson DK. Trochanteric fractures treated by the sliding screw plate fixation method. J Trauma, 1964, 4: 737-752.
21.	Mulholland RC, Gunn DR. Sliding screw plate fixation of intertrochanteric femoral fractures. J Trauma, 1972, 12(7): 581-591.
22.	Wolfgang GL, Bryant MH, O’neill JP. Treatment of intertrochanteric fracture of the femur using sliding screw plate fixation. Clin Orthop Relat Res, 1982, (163): 148-158.
23.	Brumback RJ, Ellison TS, Poka A, et al. Intramedullary nailing of femoral shaft fractures. Part Ⅲ: Long-term effects of static interlocking fixation. J Bone Joint Surg (Am), 1992, 74(1): 106-112.
24.	Niedźwiedzki L, Kunicki P, Pilut D, et al. Treatment of reverse obliquity intertrochanteric fractures. Pol Orthop Traumatol, 2012, 77: 77-82.
25.	Medoff RJ, Maes K. A new device for the fixation of unstable pertrochanteric fractures of the hip. J Bone Joint Surg (Am), 1991, 73(8): 1192-1199.
26.	Olsson O, Ceder L, Lunsjo K, et al. Biaxial dynamization in unstable intertrochanteric fractures Good experience with a simplified Medoff sliding plate in 94 patients. Acta Orthopaedica Scandinavica, 1997, 68(4): 327-331.
27.	Gotfried Y. Percutaneous compression plating of intertrochanteric hip fractures. J Orthop Trauma, 2000, 14(7): 490-495.
28.	Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. The Cochrane database of systematic reviews, 2010, (9): CD000093.
29.	Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg (Am), 2009, 91(3): 712-719.
30.	Shen L, Zhang Y, Shen Y, et al. Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: A meta-analysis of randomized controlled studies. Orthopaedics & Traumatology, Surgery & Research, 2013, 99(4): 377-383.
31.	Kuderna H, Böhler N, Collon DJ. Treatment of intertrochanteric and subtrochanteric fractures of the hip by the Ender method. J Bone Joint Surg (Am), 1976, 58(5): 604-611.
32.	Chapman MW, Bowman WE, Csongradi JJ, et al. The use of Ender’s pins in extracapsular fractures of the hip. J Bone Joint Surg (Am), 1981, 63(1): 14-28.
33.	Zickel RE. A new fixation device for subtrochanteric fractures of the femur: a preliminary report. Clin Orthop Relat Res, 1967, 54: 115-123.
34.	Templeton TS, Saunders EA. A review of fractures in the proximal femur treated with the Zickel nail. Clin Orthop Relat Res, 1979, (141): 213-216.
35.	Davis AD, Meyer RD, Miller ME, et al. Closed Zickel nailing. Clin Orthop Relat Res, 1985, (201): 138-146.
36.	Halder SC. The Gamma nail for peritrochanteric fractures. J Bone Joint Surg (Br), 1992, 74(3): 340-344.
37.	Calvert PT. The Gamma nail—a significant advance or a passing fashion? J Bone Joint Surg (Br), 1992, 74(3): 329-331.
38.	Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures. Injury, 1999, 30(5): 327-332.
39.	Werner-Tutschku W, Lajtai G, Schmiedhuber G, et al. Intra- and perioperative complications in the stabilization of per- and subtrochanteric femoral fractures by means of PFN. Unfallchirurg, 2002, 105(10): 881-885.
40.	Boldin C, Seibert FJ, Fankhauser F, et al. The proximal femoral nail (PFN)—a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand, 2003, 74(1): 53-58.
41.	Sharma A, Mahajan A, John B. A comparison of the clinico-radiological outcomes with proximal femoral nail (PFN) and proximal femoral nail antirotation (PFNA) in fixation of unstable intertrochanteric fractures. J Clin Diagn Res, 2017, 11(7): R5-R9.
42.	Lenich A, Fierlbeck J, Al-Munajjed A, et al. First clinical and biomechanical results of the Trochanteric Fixation Nail (TFN). Technol Health Care, 2006, 14(4-5): 403-409.
43.	Flores SA, Woolridge A, Caroom C, et al. The utility of the tip-apex distance in predicting axial migration and cutout with the trochanteric fixation nail system helical blade. J Orthop Trauma, 2016, 30(6): e207-211.
44.	Simmermacher RK, Ljungqvist J, Bail H, et al. The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury, 2008, 39(8): 932-939.
45.	Büttner O, Styger S, Regazzoni P, et al. Stabilization of inter- and subtrochanteric femoral fractures with the PFNA^®. Oper Orthop Traumatol, 2011, 23(5): 357-374.
46.	Takigami I, Matsumoto K, Ohara A, et al. Treatment of trochanteric fractures with the PFNA (proximal femoral nail antirotation) nail system-report of early results. Bull NYU Hosp Jt Dis, 2008, 66(4): 276-279.
47.	Li M, Wu L, Liu Y, et al. Clinical evaluation of the Asian proximal femur intramedullary nail antirotation system (PFNA-Ⅱ) for treatment of intertrochanteric fractures. J Orthop Surg Res, 2014, 9: 112.
48.	Ruecker AH, Rupprecht M, Gruber M, et al. The treatment of intertrochanteric fractures: results using an intramedullary nail with integrated cephalocervical screws and linear compression. J Orthop Trauma, 2009, 23(1): 22-30.
49.	Nherera L, Trueman P, Horner A, et al. Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures. J Orthop Surg Res, 2018, 13(1): 46.
50.	Li JT, Zhang LC, Zhang H, et al. Effect of reduction quality on post-operative outcomes in 31-A2 intertrochanteric fractures following intramedullary fixation: a retrospective study based on computerised tomography findings. International orthopaedics, 2018. doi: 10.1007/s00264-018-4098-1. [Epub ahead of print].

1. Clawson DK. Intertrochanteric fracture of the hip. Am J Surg, 1957, 93(4): 580-587.
2. Scott JF. Treatment of trochanteric fractures. J Bone Joint Surg (Br), 1951, 33-B(4): 508-512.
3. Murray RC, Frew JF. Trochanteric fractures of the femur; a plea for conservative treatment. J Bone Joint Surg (Br), 1949, 31B(2): 204-219.
4. Bong SC, Lau HK, Leong JC, et al. The treatment of unstable intertrochanteric fractures of the hip: a prospective trial of 150 cases. Injury, 1981, 13(2): 139-146.
5. Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg (Br), 1949, 31-B(2): 190-203.
6. Jewett EL. One-piece angle nail for trochanteric fractures. J Bone Joint Surg, 1941, 23(4): 803-810.
7. Cleveland M, Bosworth DM, Thompson FR, et al. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg, 1959, 41-A: 1399-1408.
8. Sarmiento A. Intertrochanteric fractures of the femur: 150-degree-angle nail-plate fixation and early rehabilitation: a preliminary report of 100 cases. J Bone Joint Surg, 1963, 45(4): 706-722.
9. Dimon JH. Hughston JC. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg (Am), 1967, 49(3): 440-450.
10. Wilson JH, Rubin BD, Helbig FE, et al. Treatment of interotrochanteric fractures with the Jewett nail: experience with 1,015 cases. Clin Orthop Relat Res, 1980, (148): 186-191.
11. McLaughlin HL. An adjustable internal fixation element for the hip. Am J Surg, 1947, 73(2): 150-161.
12. Foster JC. Trochanteric fractures of the femur treated by the Vitallium McLaughlin nail and plate. J Bone Joint Surg (Br), 1958, 40-B(4): 684-693.
13. Sahlstrand T. The Richards compression and sliding hip screw system in the treatment of intertrochanteric fractures. Acta Orthopaedica Scandinavica, 1974, 45(2): 213-219.
14. Jensen JS, Michaelsen M. Trochanteric femoral fractures treated with McLaughlin osteosynthesis. Acta Orthopaedica Scandinavica, 1975, 46(5): 795-803.
15. Kolind-Øsrensen V. Comminuted intertrochanteric fracture of the femoral neck. Acta Orthopaedica Scandinavica, 1975, 46(4): 651-653.
16. Jensen JS, Sonne-Holm S, Tøbndevold E. Unstable trochanteric fractures. A comparative analysis of four methods of internal fixation. Acta Orthopaedica Scandinavica, 1980, 51(6): 949-962.
17. Dickson JA. The unsolved fracture; a protest against defeatism. J Bone Joint Surg (Am), 1953, 35-A(4): 805-822.
18. Schumpelick W, Jantzen PM. A new principle in the operative treatment of trochanteric fractures of the femur. J Bone Joint Surg (Am), 1955, 37-A(4): 693-689.
19. Pugh WL. A self-adjusting nail-plate for fractures about the hip joint. J Bone Joint Surg (Am), 1955, 37-A(5): 1085-1093.
20. Clawson DK. Trochanteric fractures treated by the sliding screw plate fixation method. J Trauma, 1964, 4: 737-752.
21. Mulholland RC, Gunn DR. Sliding screw plate fixation of intertrochanteric femoral fractures. J Trauma, 1972, 12(7): 581-591.
22. Wolfgang GL, Bryant MH, O’neill JP. Treatment of intertrochanteric fracture of the femur using sliding screw plate fixation. Clin Orthop Relat Res, 1982, (163): 148-158.
23. Brumback RJ, Ellison TS, Poka A, et al. Intramedullary nailing of femoral shaft fractures. Part Ⅲ: Long-term effects of static interlocking fixation. J Bone Joint Surg (Am), 1992, 74(1): 106-112.
24. Niedźwiedzki L, Kunicki P, Pilut D, et al. Treatment of reverse obliquity intertrochanteric fractures. Pol Orthop Traumatol, 2012, 77: 77-82.
25. Medoff RJ, Maes K. A new device for the fixation of unstable pertrochanteric fractures of the hip. J Bone Joint Surg (Am), 1991, 73(8): 1192-1199.
26. Olsson O, Ceder L, Lunsjo K, et al. Biaxial dynamization in unstable intertrochanteric fractures Good experience with a simplified Medoff sliding plate in 94 patients. Acta Orthopaedica Scandinavica, 1997, 68(4): 327-331.
27. Gotfried Y. Percutaneous compression plating of intertrochanteric hip fractures. J Orthop Trauma, 2000, 14(7): 490-495.
28. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. The Cochrane database of systematic reviews, 2010, (9): CD000093.
29. Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone Joint Surg (Am), 2009, 91(3): 712-719.
30. Shen L, Zhang Y, Shen Y, et al. Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: A meta-analysis of randomized controlled studies. Orthopaedics & Traumatology, Surgery & Research, 2013, 99(4): 377-383.
31. Kuderna H, Böhler N, Collon DJ. Treatment of intertrochanteric and subtrochanteric fractures of the hip by the Ender method. J Bone Joint Surg (Am), 1976, 58(5): 604-611.
32. Chapman MW, Bowman WE, Csongradi JJ, et al. The use of Ender’s pins in extracapsular fractures of the hip. J Bone Joint Surg (Am), 1981, 63(1): 14-28.
33. Zickel RE. A new fixation device for subtrochanteric fractures of the femur: a preliminary report. Clin Orthop Relat Res, 1967, 54: 115-123.
34. Templeton TS, Saunders EA. A review of fractures in the proximal femur treated with the Zickel nail. Clin Orthop Relat Res, 1979, (141): 213-216.
35. Davis AD, Meyer RD, Miller ME, et al. Closed Zickel nailing. Clin Orthop Relat Res, 1985, (201): 138-146.
36. Halder SC. The Gamma nail for peritrochanteric fractures. J Bone Joint Surg (Br), 1992, 74(3): 340-344.
37. Calvert PT. The Gamma nail—a significant advance or a passing fashion? J Bone Joint Surg (Br), 1992, 74(3): 329-331.
38. Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures. Injury, 1999, 30(5): 327-332.
39. Werner-Tutschku W, Lajtai G, Schmiedhuber G, et al. Intra- and perioperative complications in the stabilization of per- and subtrochanteric femoral fractures by means of PFN. Unfallchirurg, 2002, 105(10): 881-885.
40. Boldin C, Seibert FJ, Fankhauser F, et al. The proximal femoral nail (PFN)—a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. Acta Orthop Scand, 2003, 74(1): 53-58.
41. Sharma A, Mahajan A, John B. A comparison of the clinico-radiological outcomes with proximal femoral nail (PFN) and proximal femoral nail antirotation (PFNA) in fixation of unstable intertrochanteric fractures. J Clin Diagn Res, 2017, 11(7): R5-R9.
42. Lenich A, Fierlbeck J, Al-Munajjed A, et al. First clinical and biomechanical results of the Trochanteric Fixation Nail (TFN). Technol Health Care, 2006, 14(4-5): 403-409.
43. Flores SA, Woolridge A, Caroom C, et al. The utility of the tip-apex distance in predicting axial migration and cutout with the trochanteric fixation nail system helical blade. J Orthop Trauma, 2016, 30(6): e207-211.
44. Simmermacher RK, Ljungqvist J, Bail H, et al. The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury, 2008, 39(8): 932-939.
45. Büttner O, Styger S, Regazzoni P, et al. Stabilization of inter- and subtrochanteric femoral fractures with the PFNA^®. Oper Orthop Traumatol, 2011, 23(5): 357-374.
46. Takigami I, Matsumoto K, Ohara A, et al. Treatment of trochanteric fractures with the PFNA (proximal femoral nail antirotation) nail system-report of early results. Bull NYU Hosp Jt Dis, 2008, 66(4): 276-279.
47. Li M, Wu L, Liu Y, et al. Clinical evaluation of the Asian proximal femur intramedullary nail antirotation system (PFNA-Ⅱ) for treatment of intertrochanteric fractures. J Orthop Surg Res, 2014, 9: 112.
48. Ruecker AH, Rupprecht M, Gruber M, et al. The treatment of intertrochanteric fractures: results using an intramedullary nail with integrated cephalocervical screws and linear compression. J Orthop Trauma, 2009, 23(1): 22-30.
49. Nherera L, Trueman P, Horner A, et al. Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures. J Orthop Surg Res, 2018, 13(1): 46.
50. Li JT, Zhang LC, Zhang H, et al. Effect of reduction quality on post-operative outcomes in 31-A2 intertrochanteric fractures following intramedullary fixation: a retrospective study based on computerised tomography findings. International orthopaedics, 2018. doi: 10.1007/s00264-018-4098-1. [Epub ahead of print].

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