How to fix a

proximal femoral
fracture?
Vilmos Vécsei, MUV,
Dept. for Trauma Surgery,
Austria
Trochanteric fx.-features:
Age: 7.+ 8. decade,
Female/Male: 3:1,
Fall to the hip,
Comorbidities,
Reduced ambulation
capacity,
typical diplacement
tendency
Surgery is indicated,
Bone quality impaired,
Danger of losing of
personal
independency,…
► Osteoporosis

► Female sex

► Caucasian race

► Slightly built individuals

► Limited physical activity.

UK
W
Actual aspects: Epidemiology
Hip fractures in Europe

~ 360 mill. population

2000 2050

400.000  750.000
100.000€ 200.000€
Trochanteric Fractures: Epidemiology

USA 2.000.000 patients

Annual overall costs

USA ~ 16 Billionen $

V. Vécsei
Per - / Subtrochanteric Fractures

70% of all femoral fx.s are situated in the proximal third

(Femoral neck, Trochanterregion)

Under the most frequent fractures an the third place –in adults

As a rule good healing tendency

The mortality rate is higher

compared to FNF

• trauma is bigger
• fracture surface is bigger
• soft tissue damage is bigger

V. Vécsei
 Etiology
Jung patient Older patient

Exceptional
Frequent
High Energy Trauma
Low Energy Trauma
Subtrochanteric >
pertrochanteric Fx Pertrochanteric >
subtrochanteric Fx
Combination with
polytrauma Multimorbidity

Prognosis depends on the Prognosis depends on the

concommitant injuries comotbidities
V. Vécsei
Loss of the inner solidity
Characteristics of trochanteric fractures

Loss of inner resistance leads to varus of the

proximal fragment,
The load transmission capacity disappears,
Shortening of the leg occures,
By excellent tendency to bony healing, since
the blood supply to the bone is not disturbed,
AVN occures seldom.
 hip [tr] fx
major cause of excess mortality - morbidity
in elderly people

most tr fx should undergo

anatomical reduction & internal fixation

bone-implant construct stable enough

early painless full weight-bearing

high health and social service expenditures

 Therapy - Goal
Quick surgical treatment, if possible within 6 hours after admission
Osteosynthesis with ambulation by full weight bearing
Atraumatic, gentle, quick surgical OP technic
Early mobilization

Avoidance of internal complications

Fast mobilization with reference to the mobility before accident

Returne to the former social surrounding

50% are returning to their former conditions

33% Mortality within one year

V. Vécsei
 “When there is
cortical instability
on one side of a
Fx. Instability

fx
as a result of
cortical overlap or
destruction,
the fx tends to
collapse
in the direction of
such instability”
Evans 49
 “In fx with
reversed
obliquity
there is
Fx. Instabily

marked
tendency
toward
medial
displacement
of the shaft
secondary to
adductor
Wright 47
muscle pull”
 Fx.
instability

reverse [oblique] tr fx
medial and lateral cortices interrupted

often also fx. line separating

GT

medialization
 Fx.
instability

multifragmentary direct [oblique] tr. fx

medial - posterior cortex interrupted

medial defect varus

posterior defect retroversion, external rotation

GT lateral defect medialization

 most trochanteric fx are unstable
65 / 122 [53%] Taeger 00
311 / 458 [68%] Barquet 03
768 / 1024 [75%] Chirodian 05

instability
likelihood of
difficulties in achieving accurate fx. reduction,
loss of reduction after fixation
Levy 92
 numerous proposed classifications

Boyd 49, Evans 49, Ehalt 50, Hafner 51, Rasmussen 53, Ramadier 56,
Wade 59, Ottolenghi 64, Decoulx 69, Ender 70, Tronzo 73,
Jensen-Michaelsen 75, Deburge 76, Kyle 79, Briot 80, Müller 80,
Müller 90, Moehring 97, Cirotteau 02

AO classification
most widely used
Classification: AO
A1: Simple (2-fragment) pertrochanteric
area fractures
A1.1 Fractures along the intertrochanteric
line
A1.2 Fractures through the greater
trochanter
A1.3 Fractures below the lesser trochanter
A2: Multifragmentary
pertrochanteric fractures
A2.1 With one intermediate fragment

A2.2 With 2 intermediate fragments

A2.3 With more than 2 intermediate
fragments

A3: Intertrochanteric fractures

A3.1 Simple, oblique
A3.2 Simple, transverse
A3.3 With a medial fragment
 Is this classification valid?

is it

easy to use on clinical grounds?

all inclusive and mutually exclusive?

reproducible?
[intra- & interobserver agreement]

associated with relevant patient outcomes

given specific fx. management plans?

Audigé 02
 AO classification tr fx

with subgroups
poor reproducibility
unacceptable system

without subgroups
acceptable validity
acceptable system

Henry 98, Newey 93, De Boeck 94, Schipper 01, Pervez 02,
 osteoporosis
low bone mass
deterioration bone microarchitecture
bone fragility

poor
implant
anchorage
in
bone
 assessment of osteoporosis prior to surgery
essential in predicting fx fixation stability

Singh’s rx grading (VI to I) trabecular patterns proximal femur

low reproducibility – poor correlation with DXA
Kranendonk 72, Khairi 76, Pogrund 79, Pogrund 81, Sartoris 85,
Hübsch 92, Masud 95, Koot 96, Soontrapa 05
Singh III or lower - increased incidence of fixation failure
useful for clinical purposes
Dequeker 74, Laros 74, Pogrund 81, Horsman 82,

Leichter 82, Lips 84, Gluer 94, Sinha 00

I II III

IV V VI
 AO classification without subgroups

stable unstable unstable

Singh classification in 2 groups: I-III and IV-VI

I II III IV V VI

higher incidence fixation failure lower incidence fixation failure

 may provide
valid guidelines
correctly developed surgical treatment
unstable trochanteric fx

“correctly developed
reduction and current internal fixation techniques
reduce fixation failures to 3.6 % in unstable tr fx”
Chirodian 05
 series with similar distribution of
osteoporosis severity and tr fx. classes

significant differences in fixation failures

influencing factors other than

osteoporosis and fx. geometry

surgical treatment
 fixation failure in tr
fx
stable fx 1 -
9%
unstable fx 2 -
26%
Kyle 79, Kaufer 80, Jensen 81, Heyse-Moore 83, Rao 83, Caudle 87,
Simpson 89, Clark 90, Davis 90, Laros 90, van der Schilden 90,
Nungu 91, Leung 92, Barrios 93, Desjardins 93, Radford 93,
Gundle 95, Stappaerts 95, Albareda 96, Buciuto 98, Barquet 97,
Watson 98, Lünsjo 00, Taeger 00, Kukla 01, Docquier 02, Banan 02,
Barquet 00, Hesse 04, Chirodian 05, Hernández 05
 surgeon - patient’s tr fx.

should define fx. “personality” [“class”]

osteoporotic fc? which grade?

Fx. stable or unstable? which type of

instability?

should also define patient’s “personality”

biologic age, general condition, life before fx,
medical diseases - ASA classification
 HISTORY

L. Böhler connected to the 3 flange-(blade)-nail a „sideplate“

(1940(?))

• Rigid angled implants •Double T-plate

(Jewett 1941) (Teubner )
• IM splinting • Gamma Nail
(Küntscher 1941) (Grosse,Kempf)
• Sliding plate system • Dynamic Hip Screw
(Pohl 1951) (Richards, AO)
Gerhard Küntscher Y – Nagel = Y Nail
1940 1962
Complications - Ender-nailing n= 100

nail dislocation distal < 2 cm 30 (30%)

distal > 2 cm 9 (9%)
proximal = 1,5 cm 1 (1%)
cut out 4 (4%)
FN-perforation 2 (2%)
total 46%
Ender
Simon-Weidner, 1972
The Gamma Nail 1988
Osteosynthesis
 s
l
i
d
i
n
g

extramedullary intramedullary
implants implants

controled fracture impaction

Basic principles

Bending Forces
Basic principles
a

b
 V. F. 64y, male – 0 -

?
V. F. 64y, male, - postop. 4 w -
V. F. 64y, male, - postop. 28 w -
Osteosynthesis
Biomechanical investigations
Fatigue limits DHS:
Mechanical failure: Loading capacity 1,4 kN
1)Femoral head perf. subtroch . O.: 75800 cycles
2)breaking off troch. maj. pertroch. O.: 60240 cycles
3)fx. femur at edge of plate revers subtroch.: 5000
4)bending of head screw

Fatigue limits Gamma-N.: Mechanical failure:

Loading capacity 1,6 kN
subtroch . O.: 91440 cycles 1)shaftfx. at nail tip
pertroch. O.: 71810 cycles 2)nail breakage at the eye
revers subtroch.: 44200 3)slow cut-out
Kreusch-Brinker R., et al.: „The Gamma Locking Nail“ Einhorn, Reinbek
Biomechanical examination GN, DHS with
butress plate (Sowbone, 1 pair cadaver femora)
Cycles Load
Weight Deformati
alternating bearing on
(N) capacity (mm)
100.000
Stat. Max. (N)
DHS 4,000 2,000 2,465- 17,3±
Stat. Max.
3,049 2,06
15,800 max.
(1x)
GN 4,000 2,000 4,230 - 10,73±
Stat. Max.
5,557 4,33
100.000 13,3
(2x)
Friedl W., Clausen J.: Chirurg (2002) 72: 1344 - 1352
Biomechanical examination GN, Gamma, PFN
(Sowbone, 3 pairs of cadaver femora)
3 1000 1000 6000
specimen cycles/ cycles/ cycles/
1000 N 1500 N 1000 –
migration migration 3000 N
GN 0,7 mm

Gamma 1,69 mm higher 2 double

rotation

PFN 2 mm higher 3 double

1 cut out cut out

Friedl W., Clausen J.: Chirurg (2002) 72: 1344 - 1352

TECHNICAL HINTS
...... Accurate positioning
...... Accurate positioning
.....accurate reduction is the key!!!

.....even if an open reduction

is necessary!!!
.... correct entry point
.... anatomy !!!
...correct lag screw/blade
position is crucial...
 OP technique

Correct positioning on the traction table Correct position /

Lenght
Closed reduction in good alignement Headcrew

Spiroid blade
Use of 2 image intensifier
cranial cranial

a./p. axial

v d v d
Caution!!! Wrong position of implant

Displacement at the fracture

Cut out of the head screw caudal caudal

V. Vécsei
 Comparative clinical studies
► DHS vs. Gamma ► If any only slight
► PFN vs. Gamma differences,
► small numbers of
► TGN vs. DHS
participants,
► TGN vs. Ace ► randomisation questionable,
► PFN vs. TGN ► differences often caused
► AMBI vs. TGN vs.PFN by surgical pitfalls and
failures, than by
► HP, TEP vs. PFN superiority or inferiority of
the implants
 DHS vs. Gamma Nail
DHS (n=15) Gamma Nail (n=43)
Fractures of the - 4
femoral shaft
Deep infection - 1
Reoperation 4 4
Fracture displacement 1 -

Mortality 13.3% 18.6%

Walking alone 33% 29%
Without aids 8% 20%
Overall complications 26% 16%

Saarenpää et al. International Orthopedics 2007;31:65-70

 DHS and Gamma Nail
No differences between DHS and Gamma nails
regarding operative time, blood loss, wound
complications or patient mobility.
Gamma nail had better placement in the femur

Cut out rate: DHS 5.8%

Gamma Nail 4%
Geiger et al.
 Dynamic hip screw vs. PFN

Patient's recovery after operative treatment:

(PFN=42, DHS=41)

Restoration of walking ability was

achieved more often in the patients
treated with PFN (76.2%) compared
with those treated with DHS (53.7%)

Pajarinen J. 108 patients prospective - randomized. JBJS 2005

 Compression hip screw vs. Gamma Nail
CHS (n=216) Gamma Nail (n=210)

Cut out of the femoral 2% 8%

head
Problems with distal - 14%
locking
Additional fracture 2 patients 5 patients
perioperatively
Fracture reduction 3% 2%
unsatisfactory
Fracture union 88% 95%

Ahrengart et al. Clinical Orthop Rel. Res. 2002

V. Vécsei
 bone fragility & fx. instability
adversely influence strength of bone-implant construct

facilitate “fixation failure”

varus displacement, retroversion, medialization, cut out,

collapse, pull off side plate, implant failure …

 Criteria for implant selection

Weight bearing-stability

Acceptable anchorage
osteoporotic bone

Protection of bone vascularity

Possibility of dynamization (implant+fracture)

Simple implantation technique

Sadowski C et al: J Bone Joint Surg 84: 372-381

(2002)
V. Vécsei
August 1992 - February
1998

one level I trauma centre

1000 consecutive cases
839 unstable fractures
78 trauma surgeons involved
average pt´s age: 81.2 yrs
Prospective study:

intra- and postoperative

complications
learning curve of one department
prognostic factors
 Analysis
IOP: intraoperative problems
misdrilling
shaft fractures
open reduction
rotational deformity
 Analysis
POP: postoperative problems
cutting out of lag screw
hematoma, DVT
shaft fracture
non-union, implant failure
Fracture classification

31A1 31A2 31A3

32A, B

n:161 n:741 n:86 n:12

16,1% 74,1% 8,6% 1,2%
 Intraoperative (IOP), early (
and with

Misdrilling
femoral shaft fracture
open reduction
rate of intraoperative
complications (n : 63)
G 1: 11%
G 2: 1.4%
intraoperative problems (n :
63 ))

highly significant risk ratio of

0.5 (p=0.0001) in the
incidence of IOP in relation to
increasing experience
the patients´ risk of sustaining
an IOP was reduced by 50%
each year
Prognostic factors such as
age, ASA-score, associated
injuries or earlier injuries to the

contralateral hip had no

influence on the frequency of
intraoperative complications
postoperative complications (n :
67)

significant decrease (p = 0.001)

in group G2 (5%) compared to
group G1 (8.4%)
 early postoperative
complications (5.2%)

significant effects of surgical

experience (p=0.0042), and
ASA-score (p=0.0036)
cutting out of hip screw

(n : 17)

revision due to hematoma

(n : 5)

superficial wound

infection (n : 3)
 deep wound infection (n : 14)

deep vein thrombosis (n : 7)

early postop. shaft fractures (n : 3)

te postoperative complications (1.3%)
femoral shaft fractures (n : 5)
cutting out of hips screw (n : 4)
deep wound infections (n : 3)
negative correlation between
age and risk for late POP
risk for POPlate decreased 6.2%
per additional decade
 no significant influence of
surgical experience and ASA
score for POPlate
Complications in comparison
 early complications
n = 250 1997 – 2000 / Ø 78,9 J

Gamma-Nail PFN

Infections 4 4
Serom 21 19
Hematoma 13 17
Fx. of the trochanter major 19 5
Re-Operations 1 4

58 49
Herrera A et al: Int Orthop 26: 365-369 (2002)
V. Vécsei
 Late complications
n = 250 1997 – 2000 / Ø 78,9 J

Gamma-Nagel PFNA

5 1
Cut out
Sec. Varus displacement (>10%) 2 9
„Pain in the muscle“ 7 4
Calcification - tip of trochanter 8 6
Migration of head screw 4 10
Diaphyseal fractures 4 0

30 30
Herrera A et al: Int Orthop 26: 365-369 (2002)
V. Vécsei
Complication (%) Gamma PFN GN DHS HP
Intraop. Shaft 1,2 (0- 2,6 1,0
3.3) (1-17)
fracture
Head perforation 2,3

Wound healing dis. 6,0 4,0

Postop. Shaft 2,2 1,4

fracture
Failure of locking 9,7 0,3

Infection 1,2 2,2

Cut out 3,2 2,6- 3,7 5,8

9,8
Non-union 5,0 12,0

Joint dislocation 12,0

Mortality <1 y 18,6 21,4 13,3 34,2

 How to avoid complications

Correct implant placement

Correct lenght of Plate- a. Screws

correct implant selection following fx. configuration

After care related to nature of fracture and

bony quality (to be adapted)

V. Vécsei
Prosthesis
Complications: THR vs PFN
THR PFN
Dislocation 12%
Cutting out, 9.8%
non - union
Implantation 115 84
time
Mortality 34.2% 21.4%
Geiger F. Arch.Orthop.Trauma Surg 2007
Indication for primary THR
onlySuggestions
in severe OA with
joint stiffness
Osteosynthesis whenever
possible
Use intramedullary
implants
Place Lag Screw distally
Provides good bone stock
for THR
 „Since we use total hip
arthroplasty only in
patients of good physical
shape and with severe
osteoarthritis we did not
see any dislocations“

Geiger F. Arch.Orthop.Trauma Surg 2007

E.E. 66y, f., - 0 -
E.E. 66y, m., - op. 0 d -
E.E. 66y, f., -5d -
E.E. 66y. f., - 10d -
E.E. 66y, f., - 2.op. 12d -
 Results
► Stablefractures: Gliding
headscrew combined with a plate –
dynamic contstruct to avoid
head perforation.

► Unstable fractures: are preferably

treaten by IMHN; two screw devices help
to counteract rotational movements
of the proximal fragment, but weaken
the construct; single load
carrier need addenda to control rotational
changes of the head fragment
Absence
of medial
support
=
Defect
Long Gamma Nail
Gamma -
Nail
Medialization of the head screw
Cut out mechanism
cut out
P. Ch. 90y, female, - 0 d -
P. Ch. 90y, f., - 2 d -
P. Ch. 90y, female

03.03. 07.04. 27.04.

 P. Ch. 90y, female – the cut out mechanism

24.02. 03.03. 07.04. 12.05.

P. Ch. 90y. f., - 9d -
P. Ch. 90y, female – postop. 44d -
P. Ch. 90y, female, - postop 60 d -
P. Ch. 90y, female – postop. 75 d -
Complications - Fi-nail n = 203(Budapest)

cut-out 3%

implant related compl. total 4,4%

Cut out numbers (lit.):

Greitbauer : 2,1% (1900) 2003
Kollmar : 2,6% (764) 2003
Spitaler: 4% (100) 2004
Boldin: 4% (50) 2003
 fracture of the shaft

Failure of the target device + double locking.

Double locking has been left in 1992 –
only in exceptional cases rectified.

M.M., f, 94 y
3 we p. OP
Spontaneous fracture of the shaft

OP II

6 we p. OP 3 mo p.
OPII

M.P, m
 C.W., f, 70 y

OP I

OP II OP IV
screw and implant breakage

OP I
P.G. ,f., 90 y
 screw and implant breakage
3 mo p. OP I

P.G., f. , 90 y

OP II
 screw and implant breakage

3 mo p. OP II

P.G. f. , 90 y

OP III
 screw and implant breakage
P.G. f. , 90 y

5 mo p. OP III

OP IV
screw and implant breakage
PFN
Z-Effect
 rotational discrepancy

Z.C., 87à, w
rotational discrepancy
 Complications -
PFN n = 77 (WSP)

migration of the hip screw < 1,5 cm 4 (5%)

> 2 cm 7 (9%)
cut out 2 (2.6%)
Z - effect 1 (1,3%)
fracture of the shaft 2 (2,6%)
total 20,8%
Complications
intramedullary implants
IMHS
• “cut out”
• medialization
• “Z – effect”
• rotational discrepancy
• fracture of the shaft
• screw / implant breakage
Gamma 3 PFNA
spec. osteosynthesis
Medoff Plate

V. Vécsei
complications - Medoff plate vs
DHS

cut o
Watson, JT, Moed B, Cramer KE, Karges DE Clin. Orth. Rel. Res.,
1998
Relevant complications after treatment of an
trochanteric fx. with DHS are:

1)Varus-displacement of theproximal head

and neck fragment,

2)‘Cut-out’ of the head screw

3)Medialization of the femoral shaft.

Montage of a Trochanteric butress plate can

reduce these complications and improves the
clicial outcome.
Locking
Trochanteric Stabilization
Plate (LTSP)
– offers lateral butressing.
– Reduces excessiv sec.
impaction at the fracture,
counteracts against
medialization of the shaft.
– Reduces varus
malpositioning and
shortening of the length.
– It stabilizis the Trochanter
major
and restores the
function of M. gluteus
Locking
Trochanteric Stabilization
Plate (LTSP)

– Easy to adapt to the

anatomical requirements
– Fixation of the upper
Trochanter
with locking screws
– Lateral butressing
– Does not allow exzessive
dynamization.
– Avilable as steel or titanium
amendment
A Holes with thread for 3,5 mm locking
scews

B The arms can be shortened as needed

C Hole for the placement of an antirotational

screw
(6.5 mm cannulated, or simple
cancellous screw)

D Two holes to be fitted with corticalis

screws which are connecting the DHS
plate with the LTSP and femoral shaft

E The second prox. hole has a bigger

diameter than the head of a 4,5 mm
screw; this ellows the fixation of the DHS
plate primary to the femur.
 Insertion of the antirotational screw

With the targeting devise cranial and

parallel to the head screw.

Hints
– Tighten of the antirotational screw
and the head screw crosswise to get
the maximum possible impaction.
– If a spiral blade is in use instead of
the calssical head screw a separate
antirotational screw is not needed.
 Insertion of the locking screws

Fixation of fragment od
the trochanter with the
help of 3.5 mm locking
screws
LCP drill sleeve ist
should be inserted into
the thread of the hole.
The drill bit will be
introduced through the
sleeve.
 Fixation of the locking screws

Monocortical screws with a

lenght between 20 to 25
mm should be employed.
The application happens
with the help of one by 1.5
Nm torque limited
dynamometric screwdriver.
The dynamization process
of the head screw has
priority and must not be
limited by to long locking
screws.
A new target device

► all included in
one
aiming device

► various CCD
angles

► static and
dynamic
distal locking
 ►Gamma ►Gamma 3

A new entry point – valgus angle is eliminated

Curved proximal end of the targeting device – to

avoid collision with the „soft tissues“
A new head screw
Attachment to the
tartget device
Attachment to the
tartget device
A new head
set screw
The torsional
movement of a
short head-neck
fragment around
the headscrew
can occure – to
avoid this a
spreding U-blade
can be put above
the headscrew
Secondary dynamization
• New blade design, no lag screw

• one hole for static or dynamic

distal locking

• all included in one aimimg device

76y f. – 0 -
-2d- -14 w -
....... the new blade is supposed
to compress the surrounding
cancelous bone in the
femoral neck during
insertion .......
before blade insertion after blade insertion
locking prevents blade migration
 Complications - PFNA n = 131 “first results“

2 lateral migration of the blade (... handling failure ?)

1 problem locking the blade (... product failure ?)
1 problem disconnecting the blade (... product failure?/
handling failure?)

until now one “cut out“

 locking failure

“not locking the blade“

 The treatment of
pertrochanteric fractures in
Austria

standardised questionnaire of
20 trauma-units
 stable fractures

PFN
5%
DHS
Sliding-nail 80%
5%

Gamma-nail
10%
 treatment of unstable pertrochanteric
femur fractures in Austria
DHS with or
without
various dynamic
trochanteric
nails
plate
5%
10%

PFN
25%

Gammanail
60%
 Hints, Advices and Conclusion
► IMHS devices are in unstable fx.s superior
compared to the screw+plates devices,
► The complication rate has been diminished,
► Further improvements of the results due
to techniqual development can be
expected,
► The operative rules should be followed
carefully.
Osteosynthesis

The reason for failure is

always clear to see, but on the
other hand success is
guaranteed through diligent
accuracy“
G. Küntscher (1962)