This prospective multicentre study was undertaken to determine whether the timing of the post-operative administration of bisphosphonate affects fracture healing and the rate of complication following an intertrochanteric fracture. Between August 2008 and December 2009, 90 patients with an intertrochanteric fracture who underwent internal fixation were randomised to three groups according to the timing of the commencement of risedronate treatment after surgery: Group A (from one week after surgery), Group B (from one month after surgery), and Group C (from three months after surgery). The radiological time to fracture healing was assessed as the primary endpoint, and the incidence of complications, including excessive displacement or any complication requiring revision surgery, as the secondary endpoint. The mean time to fracture healing post-operatively in groups A, B and C was 10.7 weeks (. sd. 4.4), 12.9 weeks (. sd. 6.2) and 12.3 weeks (. sd. 7.1), respectively (p = 0.420). At 24 weeks after surgery, all fractures had united, except six that had a loss of fixation. Functional outcomes at one year after surgery according to the Koval classification (p = 0.948) and the incidence of complications (p = 0.386) were similar in the three groups. This study demonstrates that the timing of the post-operative administration of bisphosphonates does not appear to affect the rate of healing of an intertrochanteric fracture or the incidence of complications

Incomplete intertrochanteric fractures do not extend across to the medial femoral cortex and are stable, without rotational deformity or shortening of the lower limb. The aim of our study was to establish whether they can be successfully managed conservatively. A total of 68 patients over a five-year period presented with a suspected fracture of the femoral neck and underwent an MRI scan for further assessment. From these, we retrospectively reviewed eight patients with normal plain radiographs but with an incomplete, intertrochanteric fracture on MRI scan. Five were managed conservatively and three operatively. The mean length of hospital stay was 16 days for the conservatively-treated group and 15 days for those who underwent surgery; this was not statistically significant (p > 0.5) and all patients were mobilised on discharge. Although five patients were readmitted at a mean of 3.2 years after discharge, none had progressed to a complete fracture. We believe that patients with incomplete intertrochanteric fractures should be considered for conservative treatment

We report the case of a 74-year-old woman who sustained an intertrochanteric fracture of the femoral neck in a previously arthrodesed hip. The hip arthrodesis had been performed 53 years earlier to treat septic arthritis. The fracture was treated successfully using a double-plating technique with 4.5 mm titanium reconstruction plates

In March 2012, an algorithm for the treatment of intertrochanteric fractures of the hip was introduced in our academic department of Orthopaedic Surgery. It included the use of specified implants for particular patterns of fracture. In this cohort study, 102 consecutive patients presenting with an intertrochanteric fracture were followed prospectively (post-algorithm group). Another 117 consecutive patients who had been treated immediately prior to the implementation of the algorithm were identified retrospectively as a control group (pre-algorithm group). The total cost of the implants prior to implementation of the algorithm was $357 457 (mean: $3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052 to 4133)) after its implementation. There was a trend toward fewer complications in patients who were treated using the algorithm (33% pre- versus 22.5% post-algorithm; p = 0.088). Application of the algorithm to the pre-algorithm group revealed a potential overall cost saving of $70 295. The implementation of an evidence-based algorithm for the treatment of intertrochanteric fractures reduced costs while maintaining quality of care with a lower rate of complications and re-admissions. Cite this article: Bone Joint J 2014;96-B:1192–7

The spiral blade modification of the Dynamic Hip Screw (DHS) was designed for superior biomechanical fixation in the osteoporotic femoral head. Our objective was to compare clinical outcomes and in particular the incidence of loss of fixation. . In a series of 197 consecutive patients over the age of 50 years treated with DHS-blades (blades) and 242 patients treated with conventional DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were identified from a prospectively compiled database in a level 1 trauma centre. Using propensity score matching, two groups comprising 177 matched patients were compiled and radiological and clinical outcomes compared. In each group there were 66 males and 111 females. Mean age was 83.6 (54 to 100) for the conventional DHS group and 83.8 (52 to 101) for the blade group. Loss of fixation occurred in two blades and 13 DHSs. None of the blades had observable migration while nine DHSs had gross migration within the femoral head before the fracture healed. There were two versus four implant cut-outs respectively and one side plate pull-out in the DHS group. There was no significant difference in mortality and eventual walking ability between the groups. Multiple logistic regression suggested that poor reduction (odds ratio (OR) 11.49, 95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent predictors of loss of fixation. . The spiral blade design may decrease the risk of implant migration in the femoral head but does not reduce the incidence of cut-out and reoperation. Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used. Cite this article: Bone Joint J 2015;97-B:398–404

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices. We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1–A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively. The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student’s t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher’s exact test, p < 0.02. The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture

We compared 54 patients treated by a Medoff sliding plate (MSP) with 60 stabilised by a compression hip screw (CHS) in a prospective, randomised study of the management of intertrochanteric femoral fractures. Four months after the operation femoral shortening was determined from radiographs of both femora. In unstable fractures the mean femoral shortening was 15 mm with the MSP and 11 mm with the CHS (p = 0.03). A subgroup in which shortening was classified as large, comprising one-third of the patients in each group, had a similar extent of shortening, but more medialisation of the femoral shaft occurred in the CHS (26%) than in the MSP (12%) group (p = 0.03). Five postoperative failures of fixation occurred with the CHS and none with the MSP (p = 0.03). The marginally greater femoral shortening seen with the MSP compared with the CHS appeared to be justified by the improved control of impaction of the fracture. Biaxial dynamisation in unstable intertrochanteric fractures is a safe principle of treatment, which minimises the rate of postoperative failure of fixation

External fixation was used in the treatment of 154 intertrochanteric fractures of the femur over a period of eight years. Good fixation and early ambulation was achieved in all cases. Blood loss was slight. There were 12 deaths due to medical causes unrelated to the surgical procedure. Deep pin-track infection occurred in six cases and late displacement of the fracture fragments in nine. The average time for union was 16 weeks. The technique is simple, quick and inexpensive, and causes minimal surgical trauma. All these features are particularly relevant where resources are limited

Failure of fixation is a major complication of the treatment of unstable intertrochanteric fractures. A retrospective review was performed of 54 such fractures treated with a sliding screw-plate device. Linear and angular displacements were calculated from radiographs taken at operation and serially until healing was complete. Linear displacement was related to fracture instability, but the neck-shaft angle was relatively constant during healing. Complications were often due to failure of the sliding mechanism of the implant. We conclude that a sliding screw-plate allows controlled collapse of the major fragments but maintains the neck-shaft angle even in unstable fractures

We conducted a prospective randomised trial to compare the results of anatomical reduction and medial displacement osteotomy in 127 consecutive patients with unstable intertrochanteric fractures, of whom 109 completed the study. After an average follow-up of 11 months, we found no significant differences in walking ability, social status or failure of fixation in the two groups. Postoperative complication rates and the early mortality rate were not significantly different, but operating time and blood loss were significantly higher in the osteotomy group. With the use of modern sliding hip screws, medial displacement osteotomy is rarely indicated for unstable intertrochanteric fractures

One hundred and seven patients with intertrochanteric fractures of the femur treated with a Richards screw-plate were compared retrospectively with 103 patients treated with a Jewett nail-plate. The mortality and morbidity were similar in the two groups. In patients with comparable fractures, those treated with a Richards device mobilised more quickly and left hospital sooner, and more of them returned to their homes. Failures of stabilisation, both clinically and radiographically, were fewer in this group. The reliability of fixation with a correctly positioned Richards screw-plate could justify the omission of outpatient follow-up in all but a small group of patients with severe unstable fractures or grossly defective bone stock. The higher cost of a Richards implant and the slightly longer operative procedure were outweighed by savings in occupancy of acute and long-stay hospital beds

Nonunion of intertrochanteric fractures is uncommon but its effects are disabling. We describe a modification of the medial displacement and valgus osteotomy of Dimon and Hughston (1967) which we used in seven fractures, six of which united within 16 weeks. Postoperatively, hip function was good. The method provides good initial stability, a source of cancellous bone graft, good postoperative hip abductor function and reliable healing of the nonunion without the need for intraoperative imaging

We have prospectively compared the fixation of 100 intertrochanteric fractures of the proximal femur in elderly patients with random use of either a Dynamic Hip Screw (DHS) or a new intramedullary device, the Gamma nail. We found no difference in operating time, blood loss, wound complications, stay in hospital, place of eventual discharge, or the patients' mobility at final review. There was no difference in failure of proximal fixation: cut-out occurred in three cases with the DHS, and twice with the Gamma nail. However, in four cases fracture of the femur occurred close to the Gamma nail, requiring further major surgery. In the absence of these complications, union was seen by six months in both groups

We performed a randomised, prospective trial in 111 patients with intertrochanteric fractures of the hip comparing the use of the Gotfried percutaneous compression plate (PCCP) with that of the classic hip screw (CHS). Blood loss and transfusion requirement were less in the PCCP group but the operating time was significantly longer. The complication rate after operation was similar in both groups, and at a minimum follow-up of six months there was no difference in the rates of fracture healing or implant failure. The PCCP gives results which are similar to those obtained with a conventional device. Its suggested advantages seem to be theoretical rather than practical and, being a fixed-angle implant, it is not universally applicable

Osteotomy has been used in the treatment of unstable intertrochanteric hip fractures in an attempt to increase the stability of the fracture fragments. We have assessed this stability in a randomised prospective trial on 100 consecutive patients, all having fixation by an AO dynamic hip screw, comparing anatomical reduction with two types of osteotomy. The groups were similar in terms of age, gender, mental test score, and fracture configuration. There were more failures of fixation in the osteotomy groups, and the operations took longer. We found no clear benefit from osteotomy and therefore recommend anatomical reduction and fixation by a sliding hip screw in most cases. Rarely, a fracture configuration which does not allow load-sharing between the fracture fragments and the device may benefit from an osteotomy or the use of an alternative implant.

Two comparable groups of patients with fractures of the trochanteric region of the femur were studied. One hundred and sixty-five fractures had been fixed with conventional nail-plates and 132 with Ender's nails. Ender's nails gave superior results in the treatment of trochanteric fractures. The operation was quicker and less traumatic than that using conventional nail-plates and both the mortality rate and the time in hospital were reduced. More patients in the group with Ender's nails who were initially independent returned to an independent existence.