Commentary & Perspective on
"Treatment of Reverse Oblique and Transverse Intertrochanteric Fractures with Use of an Intramedullary Nail or a 95° Screw-Plate. A Prospective, Randomized Study"
By Christophe Sadowski, MD et al.

Commentary & Perspective by
J. David Blaha, MD*, Adolph J. Yates, MD*, and David F. Hubbard, MD*,
Department of Orthopedics, West Virginia University School of Medicine, Morgantown, WV

The fracture identified in this article is a very specific type of a relatively uncommon intertrochanteric fracture. It is important to point out that this is not a subtrochanteric fracture although it shares the characteristic instability of the subtrochanteric fracture.

This fracture type comprised 17% of the total number of the authors’ overall experience with intertrochanteric fractures during the study period. In a recent study of 1035 intertrochanteric or subtrochanteric fractures reviewed at an American trauma center, 5% were defined as reverse oblique injuries¹. According to the AO classification system, this injury is designated as 31-A3, (.1), (.2), (.3)², and in the Evans system as modified by Kyle et al.³, it is classified under a broader category of unstable fracture patterns. That this type of fracture presents a difficult problem was well demonstrated in the series of Haidukewych et al.¹, in which 32% of 49 patients with this fracture pattern had a failure to heal or a failure of fixation. These poor results were attributable, in part, to the implants used. Sliding hip screws, as well as blade-plates, dynamic condylar screws, and various intramedullary devices were found to be problematic.

Sadowski et al. compared the results of two methods of fixation used to treat these particularly difficult fractures in their well-conducted, randomized study. Multiple surgeons performed the procedures, however, and we must assume that all of the surgeons were equally proficient and comfortable with the differences in the fixation devices and the reduction techniques. The data on the overall ease of the procedure, difficulty with reduction, and complications must be considered with this assumption in mind.

To the authors’ credit, they carefully standardized the techniques, including the well-accepted and previously described method for fixation with use of a 95° fixed-angle screw plate (Dynamic Condylar Screw)⁴. Thirty-nine elderly patients (minimum age, fifty-five years) were randomized to operative treatment with use of either the Dynamic Condylar Screw (19 patients) or an intramedullary nail (20 patients). Preoperative data, which included assessment of social function and of mobility, confirmed that there was no significant difference between the groups, and the two groups were substantially the same except for the type of fixation device used. Operative time, the need for blood transfusion, difficulty in achieving a satisfactory reduction, and the length of hospital stay were all less for the patients who were treated with the intramedullary fixation device in comparison with those who were treated with the screw plate. At the one-year follow-up, the rate of implant failure and the number of major reoperations were both lower for patients treated with the intramedullary fixation device. The authors did not mention malunion, a problem that can lead to a varus deformity in this setting. The patients who had successful operative treatment in both groups demonstrated equivalent functional results.

The results of this study demonstrate clearly that, for this group of surgeons treating this defined, low-energy fracture in a group of elderly patients, the perioperative course and outcomes of treatment with the intramedullary fixation device were superior. These results are similar to those of a previous study in which an intramedullary hip screw was compared with a sliding screw in the treatment of the larger category of "unstable" intertrochanteric fractures; it should be noted that this same study demonstrated less favorable results of the use of the intramedullary devices in the treatment of stable fracture patterns⁵. With a longer duration of follow-up there may be a problem with the stress riser created by the distal locking screws of the intramedullary device in the osteoporotic bone of the elderly; at present, however, there are no reports to suggest this. There is considerable interest in the use of intramedullary fixation devices because of their potential for a shorter operative time, a less invasive surgical procedure (which represents the ideal form of indirect reduction), and a higher rate of union. As is so often the case, the experience of the surgeon is probably more important than the type of fixation device used. In the treatment of patients with this carefully defined subset of intertrochanteric fractures, however, the learning curve may be justified by the outcomes demonstrated in this study by Sadowski et al.

*The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References

1. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83:643-50.
2. Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Heidelberg: Springer; 1994.
3. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am. 1979;61:216-21.
4. Blatter G, Janssen M. Treatment of subtrochanteric fractures of the femur: reduction on the traction table and fixation with dynamic condylar screw. Arch Orthop Trauma Surg. 1994;113:138-41.
5. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop. 1998;348:87-94.