2938 PART XV FRACTURES AND DISLOCATIONS IN ADULTS

A B
FIGURE 55.42 “Trajectory control” (see text). Establishment of precise entry portal (A) and
protection of portal by reaming through channel (B). (Modified from Ruecker AH, Russell TA, Sanders
RW, Tornetta P: TRIGEN InterTAN: surgical technique, Memphis, 2006, Smith & Nephew.)

within the reamed lateral track and re-reaming a more medial TECHNIQUE 55.8
portal (Fig. 55.47) or by using the original portal and add-
ing an anterior-to-posterior blocking screw to correct the ■ Position the patient supine on a fracture table as de-
malaligned lateral to medial trajectory (Fig. 55.48). scribed in Technique 55.7.
■ If the lesser trochanter on the affected side is intact, ob-
PLATE FIXATION tain a fluoroscopic anteroposterior view of the contralat-
Although most RT-IIA and RT-IIB fractures can be treated eral hip with the patella facing directly anteriorly toward
with intramedullary nailing, the procedure can be more tech- the ceiling (this position can be confirmed with a true
nically difficult. Fractures that compromise the entry portal anteroposterior view of the knee). Save this image to the
often are reconstructed with a cannulated screw or small fluoroscopy machine to allow later referencing of the
plate before intramedullary nailing. A very small percentage contour of the lesser trochanter (Fig. 55.50).
of subtrochanteric femoral fractures with proximal exten- ■ Make a lateral approach to the proximal femur (see Tech-
sion that compromises the integrity of the starting portal nique 1.63).
are best treated with a proximal femoral locking plate (Fig. ■ Split the fascia lata in line with the skin incision. Split the
55.49). Some clinical reports have questioned the effective- fascia of the vastus lateralis and elevate the muscle off
ness of one manufacturer’s proximal femoral locking plate the intermuscular septum. Release the origin of the vastus
because of frequent early failures; however, biomechanical lateralis from the trochanteric ridge.
data comparing proximal femoral locking plates to blade ■ Based on preoperative imaging, choose bridge plating
plates are promising. Placement of a proximal femoral lock- or direct reduction with interfragmentary fixation and
ing plate may be technically easier than placement of a blade neutralization plating. We typically use a bridge plating
plate. A proximal femoral locking plate can be placed with technique and rely on preoperative templating of the con-
either a percutaneous or open technique based on fracture tralateral side for assessing length.
characteristics. A blade plate can be placed using direct or ■ Once appropriate alignment has been achieved, introduce
indirect reduction techniques; however, percutaneous place- the plate through the proximal wound to the level that al-
ment is not an option. A blade plate can be very useful in lows placement of a guide pin just proximal to calcar (Fig.
revision situations.␣ 55.51A). We generally use a long plate that allows place-
ment of four or five well-spaced screws (low screw density).
■ Pin the plate in place proximally and distally with provi-
sional pins (Fig. 55.51B). A cortical screw can be placed
to reduce the plate to bone as necessary.
FIXATION OF SUBTROCHANTERIC ■ Place the locking screw just above the calcar (Fig. 55.51C)
and then place a cortical screw distal to the fracture into
FEMORAL FRACTURE WITH A the shaft and reduce the shaft to the plate, paying par-
PROXIMAL FEMORAL LOCKING PLATE ticular attention to the fracture alignment.
 CHAPTER 55 FRACTURES AND DISLOCATIONS OF THE HIP 2939

A B

Entry connector

Channel reamer 12.5 mm entry reamer

C D

E F

G H

FIGURE 55.43 Fixation of subtrochanteric fracture with antegrade intramedullary nail locked in reconstruction mode. A, Patient
placed supine (or lateral) on fracture table. B, Small incision beginning approximately 3 cm proximal to greater trochanter and extended
proximally. C, Establishment of precise entry portal (medial trochanteric portal or piriformis fossa portal, depending on nail selected).
D, Introduction of combination entry reamer/channel reamer and (E) proximal reaming. F, Reduction tool used to reduce fracture (G). H,
Insertion of ball-tipped guide rod across fracture.
2940 PART XV FRACTURES AND DISLOCATIONS IN ADULTS

I J

K
FIGURE 55.43, CONT’D I, Measurement for length of nail. J, Reaming of femoral shaft sequen-
tially through the channel reamer. K, Placement of intramedullary nail and locking proximally in
reconstruction mode. SEE TECHNIQUE 55.7.

■ Because of concerns about creating a significant stress

riser at the end of the plate, we tend to avoid a bicorti-
cal locking screw and prefer either a bicortical nonlock- FIXATION OF SUBTROCHANTERIC
ing screw or a unicortical locking screw. If a bicortical FEMORAL FRACTURE WITH A BLADE
nonlocking screw is to be used, it should be placed be-
fore placement of any locking screws in the shaft. Also,
PLATE
if a bicortical nonlocking screw and outrigger are used
together, the outrigger should be set at least one hole TECHNIQUE 55.9
shorter than the length of the plate.
■ Fill the plate proximally with as many locking screws as ■ Preoperative planning for the placement of a blade plate
possible based on the individual patient’s anatomy. If an is extremely important. Even with computerized radio-
initial proximal cortical screw was placed, change it to a graphs, we use printed radiographs if available to create
locking screw. an accurate template.
■ At this point, evaluate rotation. If the lesser trochanter is ■ Position the patient supine on a fracture table as de-
intact, rotate the foot to face the patella directly anteri- scribed in Technique 55.7. Make a similar lateral exposure
orly. Compare the contour of the lesser trochanter to the as used for placement of proximal femoral locking plate
other side using the fluoroscopic image obtained at the (Technique 55.8), but extend incision significantly farther
beginning of the procedure. Careful evaluation of rota- distally, making the incision as long as the anticipated
tion is important because the typically externally rotated plate length.
proximal segment may have been internally rotated at ■ Insert a Kirschner wire into the lateral aspect of the proxi-
least to a degree with reduction of the fracture and plate mal femur at a 95-degree angle relative to the shaft and
placement. based on preoperative templating. Evaluate the position
■ Place two or three additional screws in the shaft to com- of the Kirschner wire and anteversion of the hip in both
plete the final construct (Fig. 55.51D). The decision to use planes on a lateral fluoroscopic view. Some systems have
locking or nonlocking shaft screws is influenced by the guides available that simplify preparation for chisel seat-
patient’s bone quality. ing.
■ After all screws are placed, close the incision in standard ■ Use a 3.2-mm drill bit to prepare an entrance for the
fashion. chisel just distal to the Kirschner wire into the lateral cor-
■ Clinically evaluate length and rotation before the patient tex.
is awakened from anesthesia. ■ Advance the chisel into the lateral aspect of the femur
and into the femoral neck using the Kirschner wire as a
POSTOPERATIVE CARE Touch-down weight bearing is guide. Make sure the chisel is continually oriented to the
allowed for the first 6 weeks and is advanced based on alignment of the proximal fragment with disregard for
evidence of healing on follow-up radiographs. the orientation of the distal fragment.
␣
 CHAPTER 55 FRACTURES AND DISLOCATIONS OF THE HIP 2933

trochanteric buttress plate was used for all A3 fractures and to make insertion easier (Fig. 55.38C). Rotate the guide
“considered” for A1 and A2 fractures with osteoporotic bone. laterally after the nail has been inserted approximately
Outcomes were similar between the two groups with a small, halfway down the intramedullary canal. Monitor insertion
questionably clinically significant, benefit in pain with early of the nail with lateral fluoroscopy to avoid anterior corti-
mobilization in patients treated with the InterTAN. According cal perforation.
to the authors, the addition of the trochanteric buttress plate ■ Before seating the nail completely, evaluate anteversion
did not prevent excessive medialization, which was associated with lateral fluoroscopy and rotate the nail to make sure
with postoperative pain. that the wire within the insertion handle transects the nail
In a randomized controlled trial, Sanders et al. com- and femoral head/neck.
pared the InterTAN to SSP for fixation of 249 A1 and A2 ■ Confirm appropriate nail depth with the alignment arm
fractures and found no difference in primary outcomes and fluoroscopy in the anteroposterior plane.
(Functional Independence Measure [FIM] and Timed Up ■ Remove the ball-tipped guide pin.
and Go [TUG] test). They did find significantly less short- ■ Make a small incision laterally through the skin and fascia
ening in those treated with InterTAN fixation. Subgroup and place the appropriate drill sleeve on the lateral aspect
analysis demonstrated that patients who could mobilize of the femur (Fig. 55.38D).
independently before injury and had an unstable fracture ■ Place two integrated proximal interlocking screws. Use
(31A-2) had less shortening and improved FIM and TUG the 4.0-mm drill to create a pilot hole for the 3.2-mm
scores after treatment with the InterTAN compared to guide pin and place the guide pin in the center-center
SSP. Biomechanical studies support integrated two-screw position within the femoral head to within 5 mm of sub-
proximal locking. Clinically, there may be a benefit to chondral bone (Fig. 55.38E). Measure for the length of
integrated two-screw proximal locking for intramedul- the lag screw, subtracting 5 to 10 mm from the length
lary nails in the treatment of intertrochanteric femoral of the pin depending on the amount of compression de-
fractures; however, large, high-quality, comparative stud- sired.
ies are still lacking.␣ ■ Use the 7.0-mm compression screw starter drill and then
the 7.0-mm compression screw drill inferior to the guide
pin to drill for the derotational bar and subsequent com-
pression screw (Fig. 55.38F), and place the derotation bar.
■ Use the 10.5-mm drill to drill over the 3.2-mm guide pin
INTRAMEDULLARY NAILING OF (Fig. 55.38G) and insert the appropriate-length lag screw
(Fig. 55.38H).
INTERTROCHANTERIC FEMORAL ■ Remove the derotation bar and insert the integrated com-
FRACTURES WITH INTEGRATED pression screw (Fig. 55.38I). Relax traction before com-
pletely compressing the fracture.
PROXIMAL INTERLOCKING SCREWS ■ Remove the drill guide handle and engage the set screw
(INTERTAN) proximally if desired.
■ Insert a distal screw or screws for dynamic or static locking
if desired.
TECHNIQUE 55.6
POSTOPERATIVE CARE Patients with intertrochanteric
■ Patient positioning, reduction, and establishment of the femoral fractures treated with an InterTAN device are al-
entry portal are as described for intramedullary nailing of lowed to bear weight as tolerated in most circumstances;
intertrochanteric femoral fractures (see Technique 55.5). however, this device may be used in more unstable frac-
■ Once the guide pin has been localized under fluorosco- ture patterns, and occasionally weight bearing needs to
py, introduce the 12.5-mm entry reamer/16-mm channel be modified based on the fracture patterns.
reamer combination through the soft-tissue guide (entry
portal tube) over the guide pin. Insert the channel reamer
to the level of the lesser trochanter (positive stop on the
Regardless of implant selected, malrotation appears
entry portal tube) (Fig. 55.38A). We usually use a long
to be frequent with intertrochanteric femoral fractures.
InterTAN and remove the entry reamer and guide pin at
Ramanoudjame et al. found malrotation of more than 15
this time, leaving the channel reamer in place.
degrees in 16 (40%) of 40 fractures on postoperative CT
■ Introduce the ball-tipped guide pin or the reducer and
scans; 14 of these were excessively internally rotated. Studies
then the guide pin and advance it to the level of the phy-
have shown that neutral rotation or internal rotation is most
seal scar.
often necessary for appropriate reduction; however, external
■ Measure for the length of the intramedullary nail.
rotation may be necessary if the greater trochanter is not
■ If necessary, ream sequentially to a diameter 1.5 mm
part of the distal segment. Although some malrotation, par-
larger than the nail to be used (Fig. 55.38B). We typically
ticularly in younger patients with femoral shaft fractures,
use a 10-mm diameter nail for intertrochanteric femoral
may be fairly well compensated, similar compensation may
fractures and ream sequentially to 11.5 mm.
not occur in geriatric patients. Interestingly, retroversion of
■ Assemble the nail and advance it into the femur. As with
the proximal femur has been found to be fairly common in
all antegrade femoral nails inserted through a trochan-
the general population, present in up to 21% of Caucasian
teric or modified medial trochanteric portal, place the nail
males; retroversion of more than 10 degrees was found
with the guide facing anteriorly to use the bow of the nail
in approximately 6% of African Americans. The method
2934 PART XV FRACTURES AND DISLOCATIONS IN ADULTS

A B C

5mm

D E F

G H I
FIGURE 55.38 Fixation of intertrochanteric fracture with InterTAN. A, Insertion of entry reamer/channel reamer to level of lesser
trochanter. B, Sequential reaming through channel reamer. C, Placement of nail beginning with guide facing anteriorly. D, Insertion of
drill sleeve through small incision. E, Placement of guide pin in center-center position in femoral head. F, Drilling for derotational bar and
subsequent compression screw. G, Drilling for lag screw with derotational bar in place. H, Insertion of lag screw. I, Insertion of integrated
compression screw. (Modified from Ruecker AH, Russell TA, Sanders RW, Tornetta P: TRIGEN InterTAN: surgical technique, Memphis, 2006, Smith
& Nephew.) SEE TECHNIQUE 55.6.
 CHAPTER 55 FRACTURES AND DISLOCATIONS OF THE HIP 2935

of calculating the version of the uninjured side initially fractures are influenced to a much greater degree by these
described by Tornetta for femoral shaft fractures also can deforming forces than subtrochanteric femoral fractures
be used for intertrochanteric femoral fractures. The version that occur farther from the lesser trochanter. The overall
of the contralateral, uninjured side is calculated by obtain- pull of the quadriceps and hamstrings results in shortening
ing a true lateral image of the hip and knee. The difference of the extremity. The integrity of the lesser trochanter also
between the values at the hip and knee is the version. This affects deforming forces, and subtrochanteric femoral frac-
value can then be used as a template for the injured side. The tures that involve the lesser trochanter may not be affected
only real drawback to this method is time, adding approxi- by the iliopsoas and therefore experience less flexion and
mately 15 minutes to the procedure. This method therefore external rotation.
may not be ideal for the sickest of patients for whom operat- The choice of positioning also can be influenced by the
ing room time should be minimized.␣ characteristics of the fracture. Intramedullary nailing of sub-
trochanteric femoral fractures can be done with the patient in
a supine or lateral position. We prefer the supine position with
a modified medial trochanteric portal for most subtrochanteric
SUBTROCHANTERIC FEMORAL femoral fractures, and we reserve the lateral position for obese
FRACTURES patients. A lateral starting point will result in varus malalign-
Fractures occurring in the area between the lesser trochanter and ment with resultant increased nonunion risk. We typically use
the isthmus of the femoral canal are considered subtrochanteric a fracture table, but a free-hand technique also can be effective
fractures. These fractures also have been described as those occur- if an adequate number of assistants are available. We typically
ring within the first 5 cm distal to the lesser trochanter. Initially use a nailing system that allows standard proximal interlock-
described by Boyd and Griffin as a variant of peritrochanteric ing as well as locking in reconstruction mode (two cephalom-
femoral fractures with a high incidence of unsatisfactory results, edullary screws). Russell-Taylor IB, IIA, and IIB fractures are
treatment of these fractures continues to be a challenge. proximally locked in reconstruction mode. Russell-Taylor IA
fractures can be locked in standard or reconstruction mode
CLASSIFICATION (Fig. 55.41); however, for IA fractures closer to the lesser tro-
Many classifications have been described since that of Boyd chanter we tend to proximally interlock the nail in recon-
and Griffin in 1949, but none has been proven to be supe- struction mode. Patients without adequate bone stock in the
rior to any other. The Russell-Taylor classification (Fig. 55.39) femoral head may be treated with a Gamma nail type device
considers the integrity of the lesser trochanter and extension or InterTAN. These nails also may be more appropriate for
of fracture lines into the piriformis fossa. subtrochanteric femoral fractures in geriatric patients because
Type I: Fractures do not extend into the piriformis fossa. they more closely match the radius of curvature of the femur.
IA: Lesser trochanter is intact. We also advocate “trajectory control” (Fig. 55.42) in the
IB: Lesser trochanter is not intact. treatment of subtrochanteric femoral fractures. Trajectory
Type II: Fractures extend into the piriformis fossa. control involves precise establishment of the proximal nail
IIA: Lesser trochanter is intact. portal under fluoroscopic guidance (Fig. 55.42A), obtaining
IIB: Lesser trochanter is not intact. anterior and lateral cortical support, and reaming through
This classification is descriptive and still guides treat- a channel (Channel Reamer, Smith & Nephew, Memphis,
ment, albeit to a lesser degree than it once may have because TN) (Fig. 55.42B), which we believe results in less eccen-
of advances in intramedullary nailing implants and tech- tric reaming and less malalignment. A retrospective study
niques. Reverse obliquity fractures often are considered revealed much less malalignment after the concept of “tra-
Russell-Taylor IB subtrochanteric femoral fractures based on jectory control” was implemented and a channel reamer was
their behavior.␣ used routinely in the treatment of subtrochanteric femoral
fractures.␣
TREATMENT
The mainstay of treatment for subtrochanteric femoral frac-
tures is intramedullary nailing. Evidence exists that intramed-
ullary implants are superior to extramedullary implants in the
treatment of most fractures in this difficult region. Certainly, INTRAMEDULLARY NAILING IN
there are circumstances in which blade plates and proximal
femoral locking plates are useful, and we occasionally use RECONSTRUCTION MODE
both of these devices.
TECHNIQUE 55.7
INTRAMEDULLARY NAILING
Understanding the deforming forces (Fig. 55.40) is extremely ■ Place the patient supine (or lateral) on a fracture table,
important in avoiding the typical malalignments and mal- with the injured extremity in traction through a skeletal
unions associated with subtrochanteric femoral fractures. traction pin or boot and the hip flexed 30 to 40 degrees
The proximal fragment is affected by the pull of the abduc- (Fig. 55.43A).
tors, external rotators, and iliopsoas. The distal fragment is ■ Use fluoroscopy to determine appropriate version. This
affected by the pull of the adductors. The results of these determination can be made by the Tornetta method de-
muscle insertions include abduction, external rotation, and scribed earlier. Alternatively, if the fracture does not in-
flexion of the proximal fragment and medialization of the volve the lesser trochanter (distal to the lesser trochanter),
distal fragment. More proximal subtrochanteric femoral the profile of the lesser trochanter relative to the knee can
2936 PART XV FRACTURES AND DISLOCATIONS IN ADULTS

be compared with the contralateral side. This method has

been shown to be fairly sensitive in detecting rotational
abnormalities. A side-to-side difference of 20% in the size
of the lesser trochanter correlates to approximately 15
degrees of rotational difference.
■ After making an incision (Fig. 55.43B), place a guide pin
on the proximal femur in a position to proceed with a
modified medial trochanteric portal (or piriformis fossa
portal) and insert the guide pin (Fig. 55.43C). If localiza-
IA IB tion of the guide pin is difficult because of abduction,
flexion, and external rotation of the proximal fragment,
enlarge the proposed lateral incision for placement of re-
construction screws and introduce a large bone-holding
forceps to correct the proximal segment deformity and
simplify guide pin placement.
■ If a piriformis nail is used, the guide pin must be “cheat-
ed” approximately 5 mm anteriorly on the lateral view to
allow placement of the two cephalomedullary screws.
■ Correct the typical deformities of the proximal segment
and hold them corrected before reaming the proximal seg-
ment. Correct any residual abduction and flexion with a
combination of ball spike pusher and elevator (Fig. 55.44).
Alternatively, place a clamp through the same incision that
IIA IIB
will be used for insertion of the cephalomedullary screws. If
instability persists after clamp removal, a cerclage wire can
be used to hold the deformities corrected (Fig. 55.45).
FIGURE 55.39 Russell-Taylor classification of subtrochanteric ■ Use the combination entry reamer/channel reamer (Fig.
femoral fractures. 55.43D) to ream the proximal femur (Fig. 55.43E), avoid-
ing eccentric reaming.
■ Use the reduction tool (Fig. 55.43F) to aid with fracture
reduction (Fig. 44.43G).
■ Insert the ball-tipped guide rod across fracture (Fig.
55.43H).
■ Measure for length of the intramedullary nail (Fig. 55.43I).
■ Ream the femoral shaft sequentially through the channel
reamer (Fig. 55.43J).
■ Place the appropriate-size intramedullary nail and, in most
patients, lock it proximally in reconstruction mode (Fig.
55.43K).
■ Drill a hole for the most distal of the cephalomedullary
screws first, just above the calcar. Leave the drill bit in
place while drilling for the second screw and also leave
this drill bit in place. Place the distal screw first and then
the more proximal screw, placing both screws in the cen-
ter of the femoral head on the lateral view.
■ Lock the nail distally with a free-hand technique (see
Technique 54.29).
■ Check rotation for any external or internal rotational ma-
lalignments. Move the hip through a range of motion at 90
degrees of flexion and compare this range of motion to the
contralateral side. A significant side-to-side difference can
be corrected by removing the distal interlocking screws,
correcting the rotation, and then relocking the nail.
See also Video 55.1.

POSTOPERATIVE CARE Patients with subtrochanteric

femoral fractures treated with an intramedullary device
typically are allowed touch-down weight bearing for the
first 6 weeks and advanced based on healing as shown on
follow-up radiographs.
FIGURE 55.40 Deforming forces acting on subtrochanteric
femoral fracture.