The Journal of Bone and Joint Surgery (American) 83:643-650 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.
Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur
George J. Haidukewych, MD,
T. Andrew Israel, MD and
Daniel J. Berry, MD
Investigation performed at the Mayo Clinic and Mayo Foundation,
Rochester, Minnesota
George J. Haidukewych, MD
T. Andrew Israel, MD
Daniel J. Berry, MD
Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
Background: The reverse obliquity fracture of
the proximal part of the femur is a distinct fracture pattern that
is mechanically different from most intertrochanteric fractures.
The purpose of this retrospective study was to determine the prevalence
of these fractures and the results and complications of different
types of internal fixation used in their treatment.
Methods: Between 1988 and 1998, 2472 consecutive
patients with a hip fracture were treated at our Level-One Trauma
Center; 1035 of the fractures were classified as intertrochanteric
or subtrochanteric. Clinical and radiographic records were retrospectively reviewed,
and fifty-five fractures with a reverse obliquity pattern
were identified. Forty-nine patients were followed until
the fracture united or a revision operation was performed. The duration
of clinical follow-up averaged eighteen months (range, three to
sixty-seven months), and the duration of radiographic follow-up
averaged fifteen months (range, three to sixty months). Fractures were
classified with the Orthopaedic Trauma Association scheme. Results
were analyzed according to the fracture pattern, type of implant,
quality of the reduction, position of the implant, and use of bone graft
at the index operation. Function was assessed on the basis of pain,
living situation, need for walking aids, need for analgesics, and
walking capacity.
Results: Thirty-two (68%) of forty-seven
hips treated with internal fixation healed without an additional
operation. Fifteen (32%) of the forty-seven failed
to heal or had a failure of fixation. The failure rate was nine
of sixteen for the sliding hip screws, two of fifteen for the blade-plates,
three of ten for the dynamic condylar screws, one of three for the
cephalomedullary nails, and zero of three for the intramedullary
hip screws. Use of the fixed-angle devices (the blade-plate and
the dynamic condylar screw) resulted in fewer failures than did
use of the sliding hip screw (p = 0.023). Eleven (46%)
of twenty-four nonanatomically reduced fractures and four
(17%) of twenty-three anatomically reduced fractures
had a failure of treatment (p = 0.060). Eleven (26%)
of forty-two fractures with an ideally placed implant and
four (80%) of five fractures with a non-ideally placed
implant had a failure of treatment (p = 0.023). Of the
fifteen fractures that failed to heal or had a failure of fixation,
five were treated with revision to a calcar-replacement prosthesis,
seven were treated with revision open reduction and internal fixation
with bone-grafting, and one was treated with bone-grafting without
revision of the fixation. Two patients refused additional surgery
because they had limited functional demands. The two-year mortality
rate was 33%. Functional results were poor, with many patients
requiring walking aids and losing the capacity for independent walking
and self-care.
Conclusions: In this series, reverse obliquity fractures
accounted for 2% of all hip fractures and 5% of
all intertrochanteric and subtrochanteric fractures. Ninety-five-degree
fixed-angle internal fixation devices performed significantly better
than did sliding hip screws. Results were also worse for fractures
with poor reduction and those with a poorly placed implant.
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