All intertrochanteric hip fractures are not alike. And because of that, each one must be evaluated and treated depending on the specific subtype of fracture present. The intertrochanteric region of the hip is just below the femoral neck. The femoral neck is the short column of bone between the main (long) shaft of the femur (thigh bone) and the round head at the top that fits into the hip socket.
About 40 per cent of all hip fractures in older adults are intertrochanteric fractures. A fall from a standing position is the most common mechanism of injury. But, of course, there are risk factors that lead to the fall — older age, fragile or thin bones from osteoporosis, poor balance, and a previous history of falls. Women seem to be at greater risk for intertrochanteric fractures compared with men.
To repeat: all hip fractures and especially all intertrochanteric hip fractures are not alike and should not be treated in the same way each time. As the author of this article points out, the location and severity of the fracture are two defining characteristics that must be considered. A fracture high up near the femoral head is different from a fracture down lower (closer to the femoral shaft).
The failure rate of surgery to repair intertrochanteric hip fractures is high — more than 50 per cent. One way to reduce this unacceptably high complication rate is to treat each and every intertrochanteric hip fracture according to its unique fracture pattern. The resulting anatomical and biomechanical changes must be reviewed and considered as well.
Stable fractures (those that are not displaced or separated and not likely to do so) can be treated with internal fixation. Fixation refers to the placement of metal plates, screws, pins, and/or wires to hold the broken pieces of bone together until they can heal. But fractures that extend up into the joint (called intracapsular) may not respond as well. Total hip replacement may be the better choice for intertrochanteric fractures labeled as severe, unstable, and/or intracapsular. Hip replacement may also be preferred when the blood supply to the hip is compromised.
The surgeon is faced with quite a challenge when making the decision as to the “best” treatment. The goal is to relieve the patient’s pain and keep him or her mobile (if they were mobile before the fracture). The first decision is whether to try and repair the fracture or replace the hip. Sometimes that decision is fairly evident. The patient’s condition, activity level, and the severity of the fracture speak for themselves.
But more often, the surgeon must weigh the odds of the hip collapsing after repair, thus causing further pain, weakness, deformity, and difficulty standing and walking. The time between the fracture and surgery will also make a difference. Studies show the best results are linked with earlier surgery (within 24 hours of the fracture).
And surgeons must keep up with current studies and data. For example, better surgical techniques and improved hardware make it possible for patients to put weight on the operated leg without fear that the screws will rip out of the bone. The author of this article also provides surgeons with an historical overview of all the ways intertrochanteric fractures have been treated in the past (from the 1700s to present time).
A description of present day fixation systems is also provided. Nails that compress allowing the fracture to sink down and stabilize itself is one of the newer approaches. Sliding devices and the use of dual screw control helps prevent neck rotation and thus reduces motion at the fracture site.
Improvements in fixation devices and plating systems are ongoing. Results of studies using various systems with different types of intertrochanteric hip fractures will continue to define and guide treatment.
Cost versus benefit and patient outcomes (function and especially return to walking for everyday activities) must be evaluated as well. There’s no point in performing expensive surgeries if the results are no better than something less complex but just as effective.
And the author’s final point? There is no “best” treatment for intertrochanteric hip fractures. They simply cannot be treated with a “one size fits all” approach. All surgeons treating patients with this type of injury are encouraged to keep up to date on research results. Likewise, surgeons in training (residents and fellows) must be given the opportunity to gain experience in the use of these devices and methods.