Morphological analysis of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WEI Wenqiang ¹ , GU Zhengrong ¹ , CUI Jin ² , ZHOU Qirong ² , LIANG Zhimin ¹ , FANG Guozheng ¹ , WANG Xiong ¹ , JI Jiaqing ¹ ,  CAO Liehu ¹

1. Department of Orthopedics, Luodian Hospital, Baoshan District, Shanghai, 201908, P.R.China;
2. Department of Orthopedics, Changhai Hospital, Shanghai, 200433, P.R.China;

Corresponding?author：

CAO Liehu, Email: traumahu@163.com

Keywords：

Femoral intertrochanteric fracture; coronal fracture; morphology; reduction

DOI：

10.7507/1002-1892.202103067

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Objective To investigate the morphology of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation.Methods The clinical and imaging data of 46 patients with femoral intertrochanteric fracture who met the selection criteria between August 2017 and October 2018 were reviewed. There were 15 males and 31 females; the age ranged from 62 to 91 years, with an average of 72.8 years. The causes of injury included walking falls in 35 cases, falling out of bed in 4 cases, and traffic accidents in 7 cases. The AO/Orthopaedic Trauma Association classification was type 31-A1 in 11 cases and type 31-A2 in 35 cases. All patients underwent closed reduction and internal fixation with intramedullary nails. During the operation, fracture reduction and fixation were performed according to the preoperative evaluation results. According to the patients’ preoperative X-ray film and CT three-dimensional reconstruction images, the direction of the coronal fracture line of the femoral intertrochanter and the morphological characteristics of the fracture block were observed; and the coronal fracture discrimination analysis was carried out for the fractures of different AO/OTA types. The percentages of coronal femoral intertrochanteric fractures diagnosed by preoperative X-ray film and CT three-dimensional reconstruction were calculated and statistically analyzed. The fracture reduction, the position of internal fixation [measurement of tip-apex distance (TAD)]. and the reliability of internal fixation were observed after operation.Results X-ray film was not easy to identify coronary fracture, and the coronal fracture line and the shape of the fracture piece weree clearly visible in CT three-dimensional reconstruction images. The morphological characteristics of the coronary fracture block: in AO/OTA 31-A1 type, the fracture line extended obliquely backward from the anterior tip of the large rotor, above the small rotor with or without small rotor fracture; in AO/OTA 31-A2 type, fracture line extended obliquely backward from the anterior tip of the large rotor to below the small rotor. Thirteen cases (28.3%) of coronal fractures were found on preoperative X-ray films, and 35 cases (76.1%) were found by CT three-dimensional reconstruction, showing significant difference (χ²=21.083, P=0.000). In AO/OTA 31-A1 type patients, the proportion of coronal fractures found by X-ray film and CT three-dimensional reconstruction was 18.2% (2/11) and 54.5% (6/11), respectively, and that in AO/OTA 31-A2 type patients was 31.4% (11/35) and 82.9% (29/35), respectively, showing significant differences (χ²=3.143, P=0.000; χ²=20.902, P=0.000). Among the 35 patients with coronal fractures, 6 cases (17.1%) of AO/OTA 31-A1 type, 29 cases (82.9%) of AO/OTA 31-A2 type. The operation time of the patient was 80-112 minutes, with an average of 95 minutes; the intraoperative blood loss was 180-450 mL, with an average of 360 mL. There was no complication such as infection, falling pneumonia, and deep vein thrombosis of the lower extremities. At 3 days after operation, the internal fixators were all in the proper position. The TAD was 0.9-1.8 cm, with an average of 1.4 cm. All patients were followed up 14-18 months, with an average of 16 months. All the fractures healed osseously, and there was no complication such as nonunion and loosening of internal fixation.Conclusion CT three-dimensional reconstruction can better identify coronal femoral intertrochanteric fractures than X-ray films, and accurately recognize and analyze the incidence and morphological characteristics of coronal fractures, which can help formulate more effective surgical strategies to promote patient recovery.

Citation： WEI Wenqiang, GU Zhengrong, CUI Jin, ZHOU Qirong, LIANG Zhimin, FANG Guozheng, WANG Xiong, JI Jiaqing, CAO Liehu. Morphological analysis of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(9): 1093-1099. doi: 10.7507/1002-1892.202103067 Copy

1.	Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg (Br), 1949, 31B(2): 190-203.
2.	Jensen JS. Classifification of trochanteric fractures. Acta Orthop Scand, 1980, 51(5): 803-810.
3.	Magaziner J, Simonsick EM, Kashner TM, et al. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol, 1990, 45(3): M101-107.
4.	Madsen JE, Naess L, Aune AK, et al. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma, 1998, 12(4): 241-248.
5.	Butt MS, Krikler SJ, Nafie S, et al. Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury, 1995, 26(9): 615-618.
6.	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.
7.	Al-yassari G, Langstaff RJ, Jones JW, et al. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury, 2002, 33(5): 395-399.
8.	Pajarinen J, Lindahl J, Michelsson O, et al. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg (Br), 2005, 87(1): 76-81.
9.	Ganz SB, Peterson MG, Russo PW, et al. Functional recovery after hip fracture in the subacute setting. HSS J, 2007, 3(1): 50-57.
10.	Banan H, Al-Sabti A, Jimulia T, et al. The treatment of unstable, extracapsular hip fractures with the AO/ASIF proximal femoral nail (PFN)—our first 60 cases. Injury, 2002, 33(5): 401-405.
11.	Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma, 2007, 21(10 Suppl): S1-133.
12.	Boyd HB, Griffin LL. Classification and treatment of trochanteric fractures. Arch Surg, 1949, 58(6): 853-866.
13.	Ma KL, Wang X, Luan FJ, et al. Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis. Orthop Traumatol Surg Res, 2014, 100(8): 859-866.
14.	Fogagnolo F, Kfuri M, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg, 2004, 124(1): 31-37.
15.	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.
16.	Baidwan NK, Naranje SM. Epidemiology and recent trends of geriatric fractures presenting to the emergency department for United States population from year 2004-2014. Public Health, 2017, 142: 64-69.
17.	Katsoulis M, Benetou V, Karapetyan T, et al. Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project. J Intern Med, 2017, 281(3): 300-310.
18.	Smeets SJ, Poeze M, Verbruggen JP. Preoperative cardiac evaluation of geriatric patients with hip fracture. Injury, 2012, 43(12): 2146-2151.
19.	Khan SK, Kalra S, Khanna A, et al. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291, 413 patients. Injury, 2009, 40(7): 692-697.
20.	Kokoroghiannis C, Aktselis I, Deligeorgis A, et al. Evolving concepts of stability and intramedullary fixation of intertro-chanteric fractures—a review. Injury, 2012, 43(6): 686-693.
21.	Cho JW, Kent WT, Yoon YC, et al. Fracture morphology of AO/OTA 31-A trochanteric fractures: A 3D CT study with an emphasis on coronal fragments. Injury, 2017, 48(2): 277-284.
22.	Tronzo RG. Symposium on fractures of the hip. Special considerations in management. Orthop Clin North Am, 1974, 5(3): 571-583.
23.	Garg B, Malhotra R, Jayaswal A, et al. Integrity of the lateral femoral wall in intertrochanteric hip fractures. J Bone Joint Surg (Am), 2007, 89(8): 1868.
24.	Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2010, (9): CD000093. doi: 10.1002/14651858.CD000093.pub5.
25.	衛禛, 熊文峰, 張世民. 轉子間骨折中股骨干近側斷面環周皮質的CT影像學測量及其臨床意義. 中國臨床解剖學雜志, 2020, 38(6): 639-645.
26.	杜守超, 張世民, 張英琪, 等. 不穩定股骨轉子間骨折前內側皮質支撐復位的影像學研究. 中國矯形外科雜志, 2018, 26(18): 1633-1638.

1. Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg (Br), 1949, 31B(2): 190-203.
2. Jensen JS. Classifification of trochanteric fractures. Acta Orthop Scand, 1980, 51(5): 803-810.
3. Magaziner J, Simonsick EM, Kashner TM, et al. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol, 1990, 45(3): M101-107.
4. Madsen JE, Naess L, Aune AK, et al. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma, 1998, 12(4): 241-248.
5. Butt MS, Krikler SJ, Nafie S, et al. Comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. Injury, 1995, 26(9): 615-618.
6. 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.
7. Al-yassari G, Langstaff RJ, Jones JW, et al. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury, 2002, 33(5): 395-399.
8. Pajarinen J, Lindahl J, Michelsson O, et al. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg (Br), 2005, 87(1): 76-81.
9. Ganz SB, Peterson MG, Russo PW, et al. Functional recovery after hip fracture in the subacute setting. HSS J, 2007, 3(1): 50-57.
10. Banan H, Al-Sabti A, Jimulia T, et al. The treatment of unstable, extracapsular hip fractures with the AO/ASIF proximal femoral nail (PFN)—our first 60 cases. Injury, 2002, 33(5): 401-405.
11. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma, 2007, 21(10 Suppl): S1-133.
12. Boyd HB, Griffin LL. Classification and treatment of trochanteric fractures. Arch Surg, 1949, 58(6): 853-866.
13. Ma KL, Wang X, Luan FJ, et al. Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis. Orthop Traumatol Surg Res, 2014, 100(8): 859-866.
14. Fogagnolo F, Kfuri M, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg, 2004, 124(1): 31-37.
15. 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.
16. Baidwan NK, Naranje SM. Epidemiology and recent trends of geriatric fractures presenting to the emergency department for United States population from year 2004-2014. Public Health, 2017, 142: 64-69.
17. Katsoulis M, Benetou V, Karapetyan T, et al. Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project. J Intern Med, 2017, 281(3): 300-310.
18. Smeets SJ, Poeze M, Verbruggen JP. Preoperative cardiac evaluation of geriatric patients with hip fracture. Injury, 2012, 43(12): 2146-2151.
19. Khan SK, Kalra S, Khanna A, et al. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291, 413 patients. Injury, 2009, 40(7): 692-697.
20. Kokoroghiannis C, Aktselis I, Deligeorgis A, et al. Evolving concepts of stability and intramedullary fixation of intertro-chanteric fractures—a review. Injury, 2012, 43(6): 686-693.
21. Cho JW, Kent WT, Yoon YC, et al. Fracture morphology of AO/OTA 31-A trochanteric fractures: A 3D CT study with an emphasis on coronal fragments. Injury, 2017, 48(2): 277-284.
22. Tronzo RG. Symposium on fractures of the hip. Special considerations in management. Orthop Clin North Am, 1974, 5(3): 571-583.
23. Garg B, Malhotra R, Jayaswal A, et al. Integrity of the lateral femoral wall in intertrochanteric hip fractures. J Bone Joint Surg (Am), 2007, 89(8): 1868.
24. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev, 2010, (9): CD000093. doi: 10.1002/14651858.CD000093.pub5.
25. 衛禛, 熊文峰, 張世民. 轉子間骨折中股骨干近側斷面環周皮質的CT影像學測量及其臨床意義. 中國臨床解剖學雜志, 2020, 38(6): 639-645.
26. 杜守超, 張世民, 張英琪, 等. 不穩定股骨轉子間骨折前內側皮質支撐復位的影像學研究. 中國矯形外科雜志, 2018, 26(18): 1633-1638.

Chinese Journal of Reparative and Reconstructive Surgery

Morphological analysis of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation

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