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Review of Repairs for Intertrochanteric Fractures

Posted on: 11/30/1999
Hip fractures can be devastating for seniors. A once independent person can end up with a series of medical issues following a broken hip. An intertrochanteric fracture of the hip is the less severe of the hip fractures. If someone breaks the hip further up, there can be problems with blood supply to the bones and leg, while this isn't the case with an intertrochanteric fracture. This area is rich in blood supply, so keeping the bones healthy isn't usually something that doctors need to worry about. These are easier to repair in most cases, as well.

The usual approach to repairing an intertrochanteric fracture is by stabilizing the hip or by putting in a replacement, a prosthesis. One of the problems that surgeons often come across, however, is the weakness of the bones surrounding the fracture. Bones must be strong enough to withstand the hardware used to stabilize the bone or for the insertion of the prosthesis, as well as being able to hold in place when the patient begins to walk again. Other issues that may cause problems include previous hip injuries, osteoarthritis, the type of break, and other medical problems the patient may have.

When orthopedic surgeons discuss intertrochanteric fractures, the fractures are classified as stable or unstable. If a fracture is comminuted, or the bone has shattered or broken into tiny pieces, this is an unstable fracture. However, despite this division of stable versus unstable, there is no clear cut agreement among surgeons as to how best treat this type of fracture. The authors of this study examined the medical literature to find the best studies that examined this issue and gathered them together into this review.

Hip fractures can be treated with either surgical or non-surgical (conservative) treatments. Since surgery is the preferred way to manage a broken hip, non-surgical treatments are usually only done if a patient is not a good candidate for surgery, usually because of health problems. The authors found a study of 106 patients, by Hornby and colleagues, that looked at patients who underwent traction and compared them with patients who had surgery to have a screw implanted into the hip to repair the fracture. At the end of the study, the researchers recommended that surgery be performed, if at all possible. Although the complication rate was low in both groups and there wasn't much of a difference in the levels of pain or discomfort, the patients who had surgery were out of the hospital faster than those who had traction. As well, those who had traction had a higher rate of losing independence after six months than did those who had surgery.

Another study of 150 patients also compared traction with surgery, but this surgery involved removing bone. The researchers in this study had what they called "excellent" results from surgery, but the important thing to note is that the nursing care must be of a very high standard in order to prevent problems, such as pressure sores in the skin, blood clots in the legs, and other problems that can arise when a person is bed ridden for long periods of time.

The authors of this article found a retrospective study, looking back at patients who have already been treated, which examined mortality rates in patients treated for this type of hip fracture who were treated with surgery or non-surgically. The results showed that patients who had surgery had a lower mortality rate than did those who were treated without surgery, overall. But, if the patients who didn't have surgery were mobilized early, being moved from the bed to the chair and back, their mortality rate dropped to that of patients who had surgery.

One advantage, if there can be an advantage, of this type of hip fracture is the bone area is usually strong enough for good repairs. By applying screws and plates, this type of implant can be successful. Repairs using the inside of the bone, intramedullary , appear to be useful for stable fractures. What this means is a nail or screw is inserted into the bone for stability. Extramedullary repairs use plates along the outside of the bone and are used more often for unstable fractures

In 1991, Bridle and colleagues investigated 100 patients with 41 stable hip fractures. The patients received either a nail for repair or a screw. When the results were analyzed the researchers found no difference between the patients in terms of how long their surgeries took, how much blood they lost, how long they stayed in hospital, nor their ability to move about six months after the surgery. These findings were repeated in another study by two other researchers, Radford and Saudan, and their teams.

More studies include one done in 2001 by Adams and colleagues, who compared the use of a nail and a screw with a side plate. They studied 400 patients. Although there was a slight disadvantage with the patients who received the nails over the screw and plate, there wasn't enough of a difference for it to be significant. Importantly, the outcome at one year after surgery was the same in both groups.
Several other studies had very similar outcomes.

The authors then reviewed the surgical outcomes, which involved how long it took to perform the surgery (surgery times), loss of blood during surgery, and how quickly and effectively patients were able to ambulate, move about. Surgery times appeared to be very similar between the intramedullary and extramedullary repairs, although there were some studies that found surgeries using sliding hip screws could take longer than others. Blood loss was the same in the surgeries, but two studies did find less blood loss with intramedullary repairs and one said there was less blood loss with the dynamic hip screw repair.

Some patients did experience a fracture in the femur (thigh bone) when intramedullary nails were used, but the researchers found that these were likely due to surgeon inexperience and hardware problems. The rate of fractures has gone down with new designs of nails. Other complications included the bones not healing, but the incidence was about the same in all groups.

Getting patients up and moving following a hip repair is vital for their overall health. Several studies found that all of the discussed treatments were the same in terms of how long it took for patients to begin ambulating again. The authors concluded that there is no agreement among surgeons as to the best way to treat intertrochanteric fractures, but they do recommend the surgical approaches described above.

If repairs aren't possible in the above-mentioned ways, the alternative is to use a hip replacement or prosthesis. For these types of fractures, replacements are not the first choice treatment because of the location of the fracture. Therefore, the surgery is more complex. It may, however, be a good option for patients who do have a degenerative arthritis or if the fracture resulted in shattered bone.

A study done in 2005 by Kim and colleagues found that there were no differences after surgery between patients who had a cementless replacement and those who had a nail repair called a proximal femoral nail (PFN). However, during surgery, patients who had PFN had a lower rate of blood loss, need for blood transfusions, and mortality rates. Another study found similar findings for after surgery, but also found that the patients who had replacements needed more blood transfusions than those who had screws.

A study that examined patients who received an implant called a bipolar hemiarthroplasty or an internal repair, found that the patients who had the implant recovered more quickly and had lower post-surgery complications, such as pressure sores or breathing problems.

To summarize the article, the authors wrote that surgery for hip fractures is improving due to new and improved techniques and hardware. Surgeons are becoming more familiar and experienced with the available technology and their ability to decide which patients require which surgery. However, because of the wide variety of patients, their fractures, and their medical histories, it doesn't seem possible to recommend one specific type of surgery over another.

Kevin Kaplan, MD, et al. Surgical Management of Hip Fractures: An Evidence-based Review of the Literature. II: Intertrochanteric Fractures. In Journal of the American Academy of Orthopaedic Surgeons. November 2008. Vol. 16. no. 11. Pp. 665-673.

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