Concept evolution and research progress of stability reconstruction for intertrochanteric fracture_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 ZHANG Shimin , HU Sunjun , DU Shouchao , ZHANG Lizhi

Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China;

Corresponding author：

ZHANG Shimin, Email: shiminchang11@aliyun.com

Keywords：

Intertrochanteric fracture; fracture reduction quality; stability; cortical support; anteromedial cortex

DOI：

10.7507/1002-1892.201904148

Video：

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Objective To summarize the evolving concept and research progress on stability reconstruction in the surgical treatment of intertrochanteric fracture.Methods Related literature and author’s own experience concerning the surgical treatment of intertrochanteric fracture were reviewed and analyzed in terms of fracture pathoanatomy, stable and unstable pattern, adequate and in-adequate reduction, primary and secondary stability, postoperative stability evaluation, and early weight-bearing.Results Intertrochanteric fracture occur at the translational area of cervico-trochanteric junction, which has a nature tendency to varus instability. Fracture reduction quality is the paramount factor and is evaluated by two views, the anteroposterior and lateral Garden alignment and cortex apposition between the head-neck fragment and the femoral shaft. Rather than the posteromedial lesser trochanteric frag ment, the cortical support concept (positive, neutral, negative) emphasizes the reduction of anteromedial cortex to a nonanatomic positive apposition or an " anatomic” neutral apposition in intraoperative fluoroscopy. Postoperative radiographic stability score provides a quantitative assessment for early weight-bearing standing and walking. However, some fractures may lose cortical contact and buttress (negative) during the process of postoperative telescoping and secondary stability. Further studies are needed to elucidate the risk factors such as tilting, swing or rotation of the head-neck fragment, and propose new preventive methods.Conclusion Stability reconstruction of intertrochanteric fracture requires adequate fracture reduction with Garden alignment and anteromedial cortical support apposition, and reliable sustainment by internal fixation implants. Early weight-bearing standing and walking is safe in patients with perfect postoperative stability score.

Citation： ZHANG Shimin, HU Sunjun, DU Shouchao, ZHANG Lizhi. Concept evolution and research progress of stability reconstruction for intertrochanteric fracture. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(10): 1203-1209. doi: 10.7507/1002-1892.201904148 Copy

1.	Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res, 1980, (146): 53-61.
2.	Sarmiento A. The stability of intertrochanteric fractures. Current Orthop Pract, 2011, 22(5): 451-455.
3.	Russell TA. Intertrochanteric fractures of the hip//Court-Brown CM, Heckman JD, McQueen MM, et al. Rockwood and greens fractures in adults. 8th eds. Philadelphia: Lippincott Williams & Wilkins, 2016: 2075-2129.
4.	陈锐, 梅炯. 股骨距的结构特点、生物力学及其临床意义. 中国临床解剖学杂志, 2016, 34(4): 476-478.
5.	Xiong WF, Zhang YQ, Chang SM, et al. Lesser trochanteric fragments in unstable pertrochanteric hip fractures: a morphological study using three-dimensional computed tomography (3-D CT) reconstruction. Med Sci Monit, 2019, 25: 2049-2057.
6.	Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res, 2004, (425): 82-86.
7.	Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg (Br), 1949, 31B(2): 190-203.
8.	张世民, 余斌. AO/OTA-2018 版股骨转子间骨折分类的解读与讨论. 中华创伤骨科杂志, 2018, 20(7): 583-587.
9.	Xiong WF, Du SC, Chang SM. Choosing an optimal implant fixation for basicervical femoral neck fractures. Injury, 2018, 49(6): 1238-1239.
10.	Carr JB. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction. J Orthop Trauma, 2007, 21(7): 485-489.
11.	Ehrnthaller C, Olivier AC, Gebhard F, et al. The role of lesser trochanter fragment in unstable pertrochanteric A2 proximal femur fractures-is refixation of the lesser trochanter worth the effort? Clin Biomech (Bristol, Avon), 2017, 42: 31-37.
12.	张世民, 张英琪, 李清, 等. 内侧皮质正性支撑复位对老年股骨粗隆间骨折内固定效果的影响. 中国矫形外科杂志, 2014, 22(14): 1256-1261.
13.	Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
14.	Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg (Am), 1995, 77(7): 1058-1064.
15.	Choo SK, Oh HK, Ko HT, et al. Effectiveness of controlled telescoping system for lateral hip pain caused by sliding of blade following intramedullary nailing of trochanteric fracture. Injury, 2017, 48(10): 2201-2206.
16.	侯宇, 姚琦, 张亘瑷, 等. 第三代 Gamma 钉与防旋股骨近端髓内钉治疗股骨粗隆间骨折术后股骨近端短缩的比较研究. 中国修复重建外科杂志, 2018, 32(3): 338-345.
17.	Cho MR, Lee JH, Kwon JB, et al. The effect of positive medial cortical support in reduction of pertrochanteric fractures with posteromedial wall defect using a dynamic hip screw. Clin Orthop Surg, 2018, 10(3): 292-298.
18.	Li J, Zhang L, 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. Int Orthop, 2019, 43(8): 1951-1959.
19.	Chang SM, Zhang YQ, Du SC, et al. Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction. Int Orthop, 2018, 42(1): 183-189.
20.	杜守超, 张世民, 张英琪, 等. 不稳定股骨转子间骨折前内侧皮质支撑复位的影像学研究. 中国矫形外科杂志, 2018, 26(18): 1633-1638.
21.	Kyle RF, Wright TM, Burstein AH. Biomechanical analysis of the sliding characteristics of compression hip screws. J Bone Joint Surg (Am), 1980, 62(8): 1308-1314.
22.	Davis TR, Sher JL, Horsman A, et al. Intertrochanteric femoral fractures. Mechanical failure after internal fixation. J Bone Joint Surg (Br), 1990, 72(1): 26-31.
23.	Abram SG, Pollard TC, Andrade AJ. Inadequate ‘three-point’ proximal fixation predicts failure of the Gamma nail. Bone Joint J, 2013, 95-B(6): 825-830.
24.	李清, 张世民. 头髓钉治疗股骨粗隆间骨折远侧交锁螺钉的研究进展. 中国修复重建外科杂志, 2014, 28(9): 1179-1182.
25.	Lee SR, Kim ST, Yoon MG, et al. The stability score of the intramedullary nailed intertrochanteric fractures: stability of nailed fracture and postoperative patient mobilization. Clin Orthop Surg, 2013, 5(1): 10-18.
26.	张世民, 主编. 老年髋部转子间骨折. 北京: 科学出版社, 2019: 146-151.
27.	Li S, Sun GX, Chang SM, et al. Simulated postoperative weight-bearing after fixation of a severe osteoporotic intertrochanteric fracture. Int J Clin Exp Med, 2017, 10(5): 8544-8554.
28.	李建涛, 张里程, 唐佩福. 股骨粗隆间骨折治疗理念与内固定器械的发展概述. 中国修复重建外科杂志, 2019, 33(1): 1-7.

1. Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res, 1980, (146): 53-61.
2. Sarmiento A. The stability of intertrochanteric fractures. Current Orthop Pract, 2011, 22(5): 451-455.
3. Russell TA. Intertrochanteric fractures of the hip//Court-Brown CM, Heckman JD, McQueen MM, et al. Rockwood and greens fractures in adults. 8th eds. Philadelphia: Lippincott Williams & Wilkins, 2016: 2075-2129.
4. 陈锐, 梅炯. 股骨距的结构特点、生物力学及其临床意义. 中国临床解剖学杂志, 2016, 34(4): 476-478.
5. Xiong WF, Zhang YQ, Chang SM, et al. Lesser trochanteric fragments in unstable pertrochanteric hip fractures: a morphological study using three-dimensional computed tomography (3-D CT) reconstruction. Med Sci Monit, 2019, 25: 2049-2057.
6. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res, 2004, (425): 82-86.
7. Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg (Br), 1949, 31B(2): 190-203.
8. 张世民, 余斌. AO/OTA-2018 版股骨转子间骨折分类的解读与讨论. 中华创伤骨科杂志, 2018, 20(7): 583-587.
9. Xiong WF, Du SC, Chang SM. Choosing an optimal implant fixation for basicervical femoral neck fractures. Injury, 2018, 49(6): 1238-1239.
10. Carr JB. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction. J Orthop Trauma, 2007, 21(7): 485-489.
11. Ehrnthaller C, Olivier AC, Gebhard F, et al. The role of lesser trochanter fragment in unstable pertrochanteric A2 proximal femur fractures-is refixation of the lesser trochanter worth the effort? Clin Biomech (Bristol, Avon), 2017, 42: 31-37.
12. 张世民, 张英琪, 李清, 等. 内侧皮质正性支撑复位对老年股骨粗隆间骨折内固定效果的影响. 中国矫形外科杂志, 2014, 22(14): 1256-1261.
13. Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
14. Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg (Am), 1995, 77(7): 1058-1064.
15. Choo SK, Oh HK, Ko HT, et al. Effectiveness of controlled telescoping system for lateral hip pain caused by sliding of blade following intramedullary nailing of trochanteric fracture. Injury, 2017, 48(10): 2201-2206.
16. 侯宇, 姚琦, 张亘瑷, 等. 第三代 Gamma 钉与防旋股骨近端髓内钉治疗股骨粗隆间骨折术后股骨近端短缩的比较研究. 中国修复重建外科杂志, 2018, 32(3): 338-345.
17. Cho MR, Lee JH, Kwon JB, et al. The effect of positive medial cortical support in reduction of pertrochanteric fractures with posteromedial wall defect using a dynamic hip screw. Clin Orthop Surg, 2018, 10(3): 292-298.
18. Li J, Zhang L, 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. Int Orthop, 2019, 43(8): 1951-1959.
19. Chang SM, Zhang YQ, Du SC, et al. Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction. Int Orthop, 2018, 42(1): 183-189.
20. 杜守超, 张世民, 张英琪, 等. 不稳定股骨转子间骨折前内侧皮质支撑复位的影像学研究. 中国矫形外科杂志, 2018, 26(18): 1633-1638.
21. Kyle RF, Wright TM, Burstein AH. Biomechanical analysis of the sliding characteristics of compression hip screws. J Bone Joint Surg (Am), 1980, 62(8): 1308-1314.
22. Davis TR, Sher JL, Horsman A, et al. Intertrochanteric femoral fractures. Mechanical failure after internal fixation. J Bone Joint Surg (Br), 1990, 72(1): 26-31.
23. Abram SG, Pollard TC, Andrade AJ. Inadequate ‘three-point’ proximal fixation predicts failure of the Gamma nail. Bone Joint J, 2013, 95-B(6): 825-830.
24. 李清, 张世民. 头髓钉治疗股骨粗隆间骨折远侧交锁螺钉的研究进展. 中国修复重建外科杂志, 2014, 28(9): 1179-1182.
25. Lee SR, Kim ST, Yoon MG, et al. The stability score of the intramedullary nailed intertrochanteric fractures: stability of nailed fracture and postoperative patient mobilization. Clin Orthop Surg, 2013, 5(1): 10-18.
26. 张世民, 主编. 老年髋部转子间骨折. 北京: 科学出版社, 2019: 146-151.
27. Li S, Sun GX, Chang SM, et al. Simulated postoperative weight-bearing after fixation of a severe osteoporotic intertrochanteric fracture. Int J Clin Exp Med, 2017, 10(5): 8544-8554.
28. 李建涛, 张里程, 唐佩福. 股骨粗隆间骨折治疗理念与内固定器械的发展概述. 中国修复重建外科杂志, 2019, 33(1): 1-7.

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