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Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of a Reoperation

¹ Bjelkes Allé 9A, I, DK-2200 Copenhagen, Denmark. E-mail address for H. Palm: hpalm{at}dadlnet.dk. E-mail address for S. Jacobsen: sjac{at}dadlnet.dk. E-mail address for S. Sonne-Holm: s.sonne-holm{at}dadl.dk. E-mail address for P. Gebuhr: peter.gebuhr{at}hh.hosp.dk

Investigation performed at the Department of Orthopaedic Surgery, Copenhagen University Hospital of Hvidovre, Hvidovre, Denmark

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the IMK-Foundation. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Methods: Two hundred and fourteen consecutive patients with an intertrochanteric fracture were treated with a 135° sliding compression hip screw with a four-hole side-plate between 2002 and 2004. The fractures were classified on preoperative radiographs according to the AO/OTA classification system. The status of the greater and lesser trochanters, the integrity of the lateral femoral wall, and the position of the implant were assessed postoperatively. Reoperations due to technical failure were recorded for six months postoperatively.

Results: Only 3% (five) of 168 patients with an intact lateral femoral wall postoperatively underwent a reoperation within six months, whereas 22% (ten) of forty-six patients with a fractured lateral femoral wall were operated on again (p < 0.001). Multivariate logistic regression analyses combining demographic and biomechanical parameters showed a compromised lateral femoral wall to be a significant predictor of a reoperation (p = 0.010). Seventy-four percent (thirty-four) of the forty-six fractures of the lateral femoral wall occurred during the operative procedure itself. A fracture of the lateral femoral wall occurred in only 3% (three) of the 103 patients with an AO/OTA type-31-A1.1, A1.2, A1.3, or A2.1 intertrochanteric fracture compared with 31% (thirty-one) of the ninety-nine with an AO/OTA type 31-A2.2 or A2.3 fracture (p < 0.001).

Conclusions: A postoperative fracture of the lateral femoral wall was found to be the main predictor for a reoperation after an intertrochanteric fracture. Consequently, we concluded that patients with preoperative or intraoperative fracture of the lateral femoral wall are not treated adequately with a sliding compression hip-screw device, and intertrochanteric fractures should therefore be classified according to the integrity of the lateral femoral wall, especially in randomized trials comparing fracture implants.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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