Research on the classification criteria of femoral intertrochanteric fractures based on irreducibility or not_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHAO Yifeng ¹ , ZHU Fenghua ¹ , CHANG Qinghua ² , LIU Jiheng ³ , ZHANG Rui ¹ , SONG Fuqiang ¹ , CHU Fenglong ¹ , ZAI Qingshu ² , GUO Wei ⁴ , YANG Xianwei ⁴ , SHI Qiang ⁵ , ZHANG Feng ⁶ , WANG Haibin ¹ ,  JIANG Zhen ¹

1. Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China;
2. Department of Orthopedics, Jiaxiang People’s Hospital, Jiaxiang Shandong, 272400, P.R.China;
3. Department of Orthopedics, Juye Hospital of Chinese Medicine, Juye Shandong, 274900, P.R.China;
4. Department of Orthopedics, Wenshang People’s Hospital, Wenshang Shangdong, 273500, P.R.China;
5. Department of Traumatic Orthopedics, Yanzhou Hospital Affiliated to Jining Medical University, Jining Shandong, 272000, P.R.China;
6. Department of Orthopedics, Yuncheng Tangta Hospital, Yuncheng Shandong, 274000, P.R.China;

Corresponding?author：

JIANG Zhen, Email: jiangzhen19820424@163.com

Keywords：

Femoral intertrochanteric fracture; irreducible fracture; classification criteria

DOI：

10.7507/1002-1892.202103233

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Objective To formulate the classification criteria of femoral intertrochanteric fractures based on irreducibility or not in order to predict the difficulty of fracture recovery.Methods A clinical data of 244 patients with closed femoral intertrochanteric fractures admitted between January 2017 and March 2020 was retrospectively analyzed. There were 116 males and 128 females with an average age of 77.9 years (range, 45-100 years). The cause of injury included falling in 190 cases, traffic accident in 36 cases, smashing in 13 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.6 days). According toAO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were classified as type 31-A1 in 38 cases, type 31-A2 in 160 cases, and type 31-A3 in 46 cases. According to whether the recovery difficulty occurred after intraoperative closed traction reset, the patients were divided into reducible-group and irreducible-group; combined with the literature and preoperative imaging data of two groups, the classification criteria of femoral intertrochanteric fractures was formulated based on the irreducibility or not. The 244 fractures were classified by the doctors who did not attend the operation according to the classification criteria, predicted the difficulty of fracture reduction, and compared with the actual intraoperative reduction situation.Results The 244 patients were divided into reducible-group (n=164, 67.21%) and irreducible-group (n=80, 32.79%) according to the intraoperative difficulty of reduction. Comparing the imaging data and characteristics of the two groups, and formulating the classification criteria of femoral intertrochanteric fractures based on irreducibility or not, the fractures were mainly divided into two categories of irreducibility and reducibility. The fractures of irreducibility category was divided into typesⅠ-Ⅴ, among which type Ⅲ was divided into subtypes 1-4; the fractures of reducibility category was divided into typesⅠand Ⅱ. Compared with the actual intraoperative evaluation results, the total accuracy rate of the doctors who did not attend the operation was 81.15% (198/244) based on the classification criteria of femoral intertrochanteric fractures. The accuracy rate of irreducibility category was 65.74% (71/108), and the reducibility category was 93.38% (127/136). All patients were followed up 13-25 months, with an average of 17.6 months. All fractures healed except 2 cases died of infection.Conclusion The classification criteria of femoral intertrochanteric fractures based on irreducibility or not can accurately predict the reducible cases preoperatively, and most of the irreducible cases can be correctly predicted in a wider way. But the classification criteria still need to be further improved and supplemented.

Citation： ZHAO Yifeng, ZHU Fenghua, CHANG Qinghua, LIU Jiheng, ZHANG Rui, SONG Fuqiang, CHU Fenglong, ZAI Qingshu, GUO Wei, YANG Xianwei, SHI Qiang, ZHANG Feng, WANG Haibin, JIANG Zhen. Research on the classification criteria of femoral intertrochanteric fractures based on irreducibility or not. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(9): 1086-1092. doi: 10.7507/1002-1892.202103233 Copy

1.	Kumar P, Rajnish RK, Sharma S, et al. Proximal femoral nailing is superior to hemiarthroplasty in AO/OTA A2 and A3 intertrochanteric femur fractures in the elderly: a systematic literature review and meta-analysis. Int Orthop, 2020, 44(4): 623-633.
2.	Moehring HD, Nowinski GP, Chapman MW, et al. Irreducible intertrochanteric fractures of the femur. Clin Orthop Relat Res, 1997, (339): 197-199.
3.	Said GZ, Farouk O, Said HG. An irreducible variant of intertrochanteric fractures: a technique for open reduction. Injury, 2005, 36(7): 871-874.
4.	Sharma G, kumar GNK, Yadav S, et al. Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility. Injury, 2014, 45(12): 1950-1957.
5.	Chandak R, Malewar N, Jangle A, et al. Description of new “epsilon sign” and its significance in reduction in highly unstable variant of intertrochanteric fracture. Eur J Orthop Surg Traumatol, 2019, 29(7): 1435-1439.
6.	Chun YS, Oh H, Cho YJ, et al. Technique and early results of percutaneous reduction of sagittally unstable intertrochateric fractures. Clin Orthop Surg, 2011, 3(3): 217-224.
7.	Hao YL, Zhang ZS, Zhou F, et al. Predictors and reduction techniques for irreducible reverse intertrochanteric fractures. Chin Med J (Engl), 2019, 132(21): 2534-2542.
8.	Ikuta Y, Nagata Y, Iwasaki Y. Preoperative radiographic features of trochanteric fractures irreducible by closed reduction. Injury, 2019, 50(11): 2014-2021.
9.	佟大可, 丁文彬, 王光超, 等. 難復性股骨轉子間骨折的臨床分型與治療. 中華創傷骨科雜志, 2017, 19(2): 109-114.
10.	Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg (Br), 1997, 79(6): 969-971.
11.	Kim Y, Dheep K, Lee J, et al. Hook leverage technique for reduction of intertrochanteric fracture. Injury, 2014, 45(6): 1006-1010.
12.	趙益峰, 姜振, 李濤, 等. 前入路微創鉗夾復位技術治療難復性股骨轉子間骨折. 中國修復重建外科雜志, 2021, 35(5): 544-549.
13.	張世民, 胡孫君, 杜守超, 等. 小轉子二分型的難復位股骨轉子間骨折手術技巧及療效分析. 同濟大學學報(醫學版), 2020, 41(6): 772-778.
14.	Zhang W, Antony Xavier RP, Decruz J, et al. Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA Ⅱ): a study in a Southeast Asian population. Arch Orthop Trauma Surg, 2021, 141(4): 569-575.
15.	Karayiannis P, James A. The impact of cerclage cabling on unstable intertrochanteric and subtrochanteric femoral fractures: a retrospective review of 465 patients. Eur J Trauma Emerg Surg, 2020, 46(5): 969-975.
16.	Buyukdogan K, Caglar O, Isik S, et al. Risk factors for cut-out of double lag screw fixation in proximal femoral fractures. Injury, 2017, 48(2): 414-418.
17.	Hao Y, Zhang Z, Zhou F, et al. Risk factors for implant failure in reverse oblique and transverse intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA). J Orthop Surg Res, 2019, 14(1): 350-357.
18.	Imerci A, Aydogan NH, Tosun K. The effect on outcomes of the application of circumferential cerclage cable following intramedullary nailing in reverse intertrochanteric femoral fractures. Eur J Orthop Surg Traumatol, 2019, 29(4): 835-842.

1. Kumar P, Rajnish RK, Sharma S, et al. Proximal femoral nailing is superior to hemiarthroplasty in AO/OTA A2 and A3 intertrochanteric femur fractures in the elderly: a systematic literature review and meta-analysis. Int Orthop, 2020, 44(4): 623-633.
2. Moehring HD, Nowinski GP, Chapman MW, et al. Irreducible intertrochanteric fractures of the femur. Clin Orthop Relat Res, 1997, (339): 197-199.
3. Said GZ, Farouk O, Said HG. An irreducible variant of intertrochanteric fractures: a technique for open reduction. Injury, 2005, 36(7): 871-874.
4. Sharma G, kumar GNK, Yadav S, et al. Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility. Injury, 2014, 45(12): 1950-1957.
5. Chandak R, Malewar N, Jangle A, et al. Description of new “epsilon sign” and its significance in reduction in highly unstable variant of intertrochanteric fracture. Eur J Orthop Surg Traumatol, 2019, 29(7): 1435-1439.
6. Chun YS, Oh H, Cho YJ, et al. Technique and early results of percutaneous reduction of sagittally unstable intertrochateric fractures. Clin Orthop Surg, 2011, 3(3): 217-224.
7. Hao YL, Zhang ZS, Zhou F, et al. Predictors and reduction techniques for irreducible reverse intertrochanteric fractures. Chin Med J (Engl), 2019, 132(21): 2534-2542.
8. Ikuta Y, Nagata Y, Iwasaki Y. Preoperative radiographic features of trochanteric fractures irreducible by closed reduction. Injury, 2019, 50(11): 2014-2021.
9. 佟大可, 丁文彬, 王光超, 等. 難復性股骨轉子間骨折的臨床分型與治療. 中華創傷骨科雜志, 2017, 19(2): 109-114.
10. Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg (Br), 1997, 79(6): 969-971.
11. Kim Y, Dheep K, Lee J, et al. Hook leverage technique for reduction of intertrochanteric fracture. Injury, 2014, 45(6): 1006-1010.
12. 趙益峰, 姜振, 李濤, 等. 前入路微創鉗夾復位技術治療難復性股骨轉子間骨折. 中國修復重建外科雜志, 2021, 35(5): 544-549.
13. 張世民, 胡孫君, 杜守超, 等. 小轉子二分型的難復位股骨轉子間骨折手術技巧及療效分析. 同濟大學學報(醫學版), 2020, 41(6): 772-778.
14. Zhang W, Antony Xavier RP, Decruz J, et al. Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA Ⅱ): a study in a Southeast Asian population. Arch Orthop Trauma Surg, 2021, 141(4): 569-575.
15. Karayiannis P, James A. The impact of cerclage cabling on unstable intertrochanteric and subtrochanteric femoral fractures: a retrospective review of 465 patients. Eur J Trauma Emerg Surg, 2020, 46(5): 969-975.
16. Buyukdogan K, Caglar O, Isik S, et al. Risk factors for cut-out of double lag screw fixation in proximal femoral fractures. Injury, 2017, 48(2): 414-418.
17. Hao Y, Zhang Z, Zhou F, et al. Risk factors for implant failure in reverse oblique and transverse intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA). J Orthop Surg Res, 2019, 14(1): 350-357.
18. Imerci A, Aydogan NH, Tosun K. The effect on outcomes of the application of circumferential cerclage cable following intramedullary nailing in reverse intertrochanteric femoral fractures. Eur J Orthop Surg Traumatol, 2019, 29(4): 835-842.

Chinese Journal of Reparative and Reconstructive Surgery

Research on the classification criteria of femoral intertrochanteric fractures based on irreducibility or not

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