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Implant options for the treatment of

intertrochanteric fractures of the hip

A. R. Socci, Aims
N. E. Casemyr, The aim of this paper is to review the evidence relating to the anatomy of the proximal
M. P. Leslie, femur, the geometry of the fracture and the characteristics of implants and methods of
M. R. Baumgaertner fixation of intertrochanteric fractures of the hip.
Materials and Methods
From Yale University Relevant papers were identified from appropriate clinical databases and a narrative review
School of Medicine, was undertaken.
Connecticut, United
States Results
Stable, unstable, and subtrochanteric intertrochanteric fractures vary widely in their
anatomical and biomechanical characteristics, as do the implants used for their fixation. The
optimal choice of implant addresses the stability of the fracture and affects the outcome.
The treatment of intertrochanteric fractures of the hip has evolved along with changes in the
design of the implants used to fix them, but there remains conflicting evidence to guide the
choice of implant. We advocate fixation of 31A1 fractures with a sliding hip screw and all
others with an intramedullary device.
Cite this article: Bone Joint J 2017;99-B:128–33.
Fractures of the hip are arguably the most The pertrochanteric region has many thick-
important public health problem faced by enings of trabecular bone in compressive and
orthopaedic surgeons. More than 250 000 low- tensile groups. The most structurally signifi-
energy fractures of the hip occur in the United cant of these are the primary compressive tra-
States each year.1 The International Osteoporo- beculae along the posteromedial femoral neck
sis Foundation2 estimates that approximately and shaft.6 While several classification systems
1.6 million such fractures occur per year world- exist for these fractures, they are all based on
 A. R. Socci, MD, Assistant wide, a figure which may rise to six million by the concept of stability. A stable fracture is a
 N. E. Casemyr, MD, Assistant
2050. Their treatment consumes a growing simple one that, once reduced and fixed, is
Professor, percentage of healthcare expenditure.2 compressed and minimally impacted by the
 M. P. Leslie, DO, Associate
The goals of care are to restore function with nearly perpendicular weight-bearing force of
 M. R. Baumgaertner, MD, the lowest possible rate of surgical and medical single leg stance.7 Unstable fractures due either
Yale University School of
complications. Achieving stable reduction and fix- to comminution, ‘reverse oblique’ orientation,
Medicine, Department of ation of the fracture, permitting immediate mobi- or both, are associated with collapse on axial
Orthopaedics and
Rehabilitation, 800 Howard
lisation, is key to these goals. loading. Both the posteromedial cortex and the
Ave, New Haven, CT 06520, The last 25 years has seen the introduction and lateral cortical buttress beneath the vastus
increasing acceptance and use of intramedullary ridge contribute to the stability of these frac-
Correspondence should be sent devices in preference to the sliding hip screw tures. The instability increases with the degree
to A. R. Socci; email: (SHS) for the treatment of intertrochanteric frac- of comminution of the posteromedial cortex.
tures.3 Despite little good quality evidence to sup- Increased comminution implies less support
©2017 The British Editorial
Society of Bone & Joint port their use, most clinicians use them for most for axial loading through cortical contact. The
Surgery fractures, and practice guidelines from the Amer- lateral cortex beneath the vastus ridge provides
BJJ-2016-0134.R1 $2.00 ican Association of Orthopaedic Surgery the final buttress to impaction of the fracture
(AAOS)4 support their use.5 In this paper we after fixation, further contributing to its stabil-
Bone Joint J
2017;99-B:128–133. review the evidence and highlight the weaknesses ity and avoiding collapse.8,9 Incompetence of
Received 24 March 2016; or absence. We also present our practice with its either of these cortical regions therefore ren-
Accepted after revision 17
August 2016 rationale and recommendations. ders a fracture unstable.



dence on prognosis,7 and is also useful for research and has

been shown to have greater inter-observer reliability than
other classification systems.14 Simple, two-part pertrochan-
teric fractures with a single line of extension into the medial
cortex are classified as 31-A1. These fractures are stable after
reduction because bony continuity is restored and a signifi-
cant proportion of the load transmitted through the proxi-
mal femur can be safely borne. Multi-fragmentary
pertrochanteric fractures beginning anywhere in the greater
trochanter with medial extension in two or more places cre-
ating a third fracture fragment, including the lesser tro-
chanter, are classified as 31-A2. Many of these are unstable
after reduction because the medial buttress is compro-
mised. Fracture patterns 31-A1.1 to 31-A2.1 are typically
stable and those from 31-A2.2 to 31-A3.3, which have
more than one intermediate fragment, are usually unsta-
ble.15 True intertrochanteric fractures with a fracture line
that passes between the trochanters, above the lesser tro-
chanter medially and below the vastus ridge laterally are
classified as 31-A3. These fractures are unstable after
reduction because both posteromedial and lateral but-
tresses are lost. This classification is particularly valuable in
its identification of reverse oblique and ‘intertrochanteric
subtrochanteric’ fractures as challenging to reduce and fix
with stability.
Involvement of the lateral cortex is only a specific crite-
rion of fractures in the 31-A3 category and is an important
Fig. 1 factor in loss of reduction when using an extramedullary
SHS system.16 Intra-operative fracture of the lateral cortical
Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma
Association classification of pertrochanteric fractures. Copyright the buttress is significantly more common in A2.2 and A2.3
AO Foundation, Switzerland. (Source: AO Surgery Reference). fractures than in A2.1 fractures,8 emphasising the impor-
tance of recognising the A2 sub-type when choosing the
implant by which it will be managed.
A surgeon’s familiarity with a specific implant may have
The quality of reduction, regardless of the pattern of the a measurable effect on the operating time, the use of fluor-
fracture, is one of the most important modifiable factors in oscopy, intra-operative blood loss and the need for transfu-
the management of intertrochanteric fractures.10 The abil- sion, but a systematic review of the evidence reported
ity of the cortex to resist collapse in stable fractures significant heterogeneity in published data and an implant-
depends on the restoration of cortical continuity. In unsta- associated effect has not therefore been shown.17
ble fractures, where the ability to restore this is limited by There is an increasing cost associated with SHSs, short
comminution or the orientation of the fracture, the bone- nails and long nails, respectively.18,19 Intramedullary
implant interface will be subject to increased stress. implants are between 20% and 40% more expensive than
Implants used to fix unstable fractures must, therefore, be SHSs and so, if each is appropriate for fracture fixation, the
capable of bearing more load, in order to avoid loss of less expensive device should be used. A recent American
reduction through collapse. A valgus reduction is one way College of Surgeons National Surgical Quality Improve-
of increasing interfragmentary compression and of reduc- ment Program database study reported a shorter mean
ing bone-implant stresses, as well as minimising collapse post-operative length of stay following treatment with an
and leg length discrepancy. intramedullary implant.20 This study did not stratify the
Studies of implant loading confirm that the load borne patients by the type of fracture and hence the effect was
by an implant is increased with varus mal-reduction and seen across all groups, implying that the greater cost of the
with decreasing stability of the fracture, and that in both implant may be offset against the ongoing cost of care by
cases an intramedullary device can bear greater load than using the intramedullary device in all patients.
an extramedullary device.11,12 Cost-effectiveness analysis that models length of stay,
The Arbeitsgemeinschaft für Osteosynthesefragen/Ortho- rehabilitation or re-operation is dependent on the data used
paedic Trauma Association classification system13 (Fig. 1) for the model, in particular those used to inform the rate of
offers both a universal descriptive language and reliable evi- failure. One such study suggested that extramedullary

VOL. 99-B, No. 1, JANUARY 2017


implants are more cost-effective for A2 fractures, but curvature and the anterior bow of the femur. A stress riser
assumed an equivalent rate of failure between SHSs and can, in this scenario, lead to a fracture which is even more
nails.18 Such an assumption ignores differences in out- challenging to manage, especially with a nail in situ.
comes, especially when considering the A2 group as a No significant difference in the rates of periprosthetic
homogenous one. fracture between short and long nails have been recorded at
Late costs are more difficult to measure and tend to one, two or five years post-operatively.21,30
relate to failure, requiring prolonged rehabilitation or re- Longer nails can cost up to 45% more than short nails.30
operation.21 First-generation intramedullary implants had Lindvall et al21 reported that, based on a rate of peri-
a significantly higher incidence of periprosthetic fracture, prosthetic fracture of 12% and an increased cost of $439 of
thereby compounding their already increased cost. A 4.5- long nails over short, long nails were cheaper than short
fold increased risk of periprosthetic fracture in 1997 ones when the cost of managing complications was taken
decreased to 1.87 in 2005 and is no longer evident in the into account. A more recent study reported equivalence
most recent data.22,23 between short and long nails, except for hospital costs
Despite a large number of randomised controlled trials (which can include facility fees, cost of medications given,
(RCTs), meta-analyses have not shown differences in func- administration of the medications, lab costs, cost of surgery
tional outcomes between intra- and extra-medullary and anesthesia).19
devices. These studies have often used inappropriate out- Leaving aside the biomechanically dissimilar subtro-
come measures and reported the outcome of diverse chanteric fractures, there is little evidence relating to short
cohorts of patients, pooled without reference to pre-opera- versus long nails in terms of functional outcome and until
tive functional status.17,24 Some authors have, however, these data are known, meaningful assessment of cost bene-
shown differences in the rates of recovery of function. In a fit is difficult.
RCT of intramedullary versus extramedullary fixation in Distal locking. The effect of distal locking on the incidence
210 patients with A1 or A2 fractures, Utrilla et al25 of periprosthetic fracture is not fully understood. Lindvall
reported no difference in outcome in stable fractures, but et al21 reported that distal locking may be protective against
better mobility at one year following intramedullary fixa- periprosthetic fracture in both short and long nails. In their
tion of unstable fractures. Improved early functional recov- cohort of 609 patients, 47% of nails were distally locked
ery following intramedullary fixation has also been shown but 15 of 16 periprosthetic fractures occurred in the 53%
in several studies which also recorded sliding of SHSs, indi- of patients with unlocked nails at 21.5 months (standard
cating shortening of the femoral neck, leg length discrep- deviation (SD) 18.6) follow-up in the short nail group and
ancy, and/or medialisation of the shaft.26-28 Pajarinen et al26 14.8 months (SD 13.8) follow-up for long nails. They also
reported improved mobility and less shortening of the fem- noted that patients with unlocked long nails experienced
oral neck after intramedullary fixation in agreement with periprosthetic fracture around the shaft, while those with
the findings of Hardy et al27 of improved early mobility, less locked long nails had fractures at the tip of the nail. In short
sliding and less leg length discrepancy. The early functional unlocked nails, fractures occurred at the tip of the nail, in
recovery is better in those in whom the SHS slides less, sug- keeping with early findings in studies of intramedullary fix-
gesting that excessive alteration of the biomechanics of the ation.33-35 This is important as, in relative terms, it is easier
hip can impair the recovery of mobility. A recent RCT by to treat a diaphyseal fracture by closed reduction with the
Reindl et al29 found less shortening of the femoral neck in introduction of a distal locking screw than it is to perform
the intramedullary group, but this did not significantly alter open reduction and internal fixation of a peri-articular frac-
the timed up and go scores. It is likely that the ability of a ture around a locked nail.
patient to tolerate malunion is related to pre-injury func- Current evidence supports distal locking in axially or
tion, but there is currently no evidence to support this as rotationally unstable fractures, including those with sub-
studies tend to pool all patients. Information about func- trochanteric extension or comminution, or in osteoporotic
tional outcomes such as return to social integration, driving femora in which it is hard to achieve an isthmic fit.32
and participation in recreational activities is urgently
needed. Femoral head fixation: blade vs screw, one vs two
Some intramedullary implants use a helical blade for fixa-
Implant details tion of the femoral head instead of a cancellous screw. Bio-
The length of the nail. Early intramedullary nails used for mechanical studies in artificial, cadaveric and living bone
fractures of the hip were short and associated with a risk of have shown that a blade resists rotational and translational
fracture at the tip of the nail, with an incidence of 8% to displacement better36,37 but this has not translated into evi-
11% historically.30 Long nails can prevent this complica- dence of a difference in rates of cut-out, complications, or
tion but risk anterior cortical impingement or intra- post-operative function.38,39 Consistently, loss of fixation is
operative iatrogenic fracture with incidences of 1.5%30 and more related to the quality of reduction of the fracture and
< 1% recorded.31,32 For this reason, the surgeon must be a high tip-apex distance (TAD) rather than the choice of
conscious of the design of the nail including its radius of implant.37,39



The use of blades may be associated with the phenome- Discussion

non of ‘cut-through’ with medial perforation of the articu- Stable intertrochanteric fractures (A1 to A2.1). There is cur-
lar surface of the femoral head without loss of reduction of rently little evidence of the superiority of one device over
the fracture.40 This is in contrast to ‘cut-out’, superior and another in the management of these fractures.5,25,28,51
anterior migration of the screw as the fracture displaces and The quality of reduction remains paramount, with stable
the femoral head moves into varus and retroversion. In fractures having direct cortical contact following accurate
order to avoid ‘cut-through’, it has been suggested that the reduction. At our institution there is a preference for SHS
full length of the trajectory of the blade is not pre-drilled fixation after careful reduction.
and that the tip of the blade should be a minimum of Subtrochanteric and reverse oblique fractures (A3). There is
10 mm from the joint surface.40,41 strong evidence to support the use of intramedullary fixa-
There are variants with both one (uniaxial) and two tion in subtrochanteric and reverse oblique fractures. The
(biaxial) screws in the femoral head. Greater load to failure biomechanics of these fractures are such that fixation with
has been reported with biaxial screws in a biomechanical a SHS is inappropriate, as the line of collapse is not perpen-
study,42 but this advantage has not been reported clinically dicular to the fracture line and the lateral cortical buttress
and complications of axial and reverse axial migration (the cannot resist collapse. The use of a trochanteric sliding
‘Z’ and ‘reverse Z’ effects) have been described.43 A pro- plate (TSP) offers increased resistance to collapse, but the
spective RCT by Kouvidis et al43 showed no difference in fixation is less reliable than when using an intramedullary
outcome (activities of daily living or mobility) between an device, which offers better functional outcomes and rates of
SHS group (60 patients) and a biaxial intramedullary nail union.27,52,53-57 Worse outcomes are also associated with
group (62 patients) at 1 year follow-up. The single system- the use of proximal femoral locking plates.58 Intramedul-
atic review of such devices suggests that biaxial fixation lary nails resist collapse both by their intramedullary posi-
leads to a lower risk of post-operative periprosthetic frac- tion and by an enlarged proximal end, offering an internal
ture than uniaxial fixation.44 This review examined only buttress. The minimally invasive nature of the surgery also
periprosthetic fracture however, without recording any preserves the vastus soft tissue envelope, maintaining sta-
other outcome or complication, including those specific to bility and vascularity.
biaxial fixation. Unstable intertrochanteric fractures (A2.2 to A2.3). Current
Proximal femoral locking plates offer a lower load to guidelines recommend the use of an intramedullary device
failure than cephalomedullary devices and have higher for the treatment of these fractures.5
rates of mechanical failure and re-operation.45 As in subtrochanteric and reverse oblique fractures, the
Much of the evidence supporting the use of newer designs use of a TSP may prevent excessive collapse in unstable
of implant is biomechanical and must be interpreted care- fractures lacking a posteromedial or lateral cortical buttress
fully to understand the clinical relevance. The native hip may in which an SHS is used.
be loaded in different directions and different ways and the A randomised prospective study comparing fixation
evidence should be evaluated with caution. using a SHS (343 patients) or intramedullary nail (341
patients) for all intertrochanteric and subtrochanteric frac-
Tip-apex distance and other targets tures showed no long-term differences in outcome at three
Both ‘cut-out’ and ‘cut-through’ emphasise the importance and 12 month follow-up, with improved early pain on
of the correct placement of the screw in the femoral head, mobilisation scores in the intramedullary group.59 Impor-
namely central and deep.46 The TAD is an accepted and tantly, a TSP was used in A3 fractures and optional in
reproducible means of evaluating this.46 A recent variation, osteoporotic A1 and A2 fractures when the lateral cortical
the ‘calcar-TAD’, aims to target a slightly inferior place- buttress was questionable. The equivalence of outcome
ment of the screw when using cephalomedullary devices. between these constructs emphasises that maintenance of a
This reflects existing practice in both SHSs and intramedul- good reduction and prevention of collapse offers optimum
lary devices, based on there being stronger bone in the cal- function. Medialisation of the femoral shaft was seen more
car and inferior femoral head.47,48 It has not, however, been frequently in the SHS/TSP group and was associated with
confirmed that this offers better fixation than when placing increased post-operative pain. Overall, an intramedullary
the screw in the centre of the femoral head.49,50 In the mul- device appears from the evidence to offer more benefit than
tivariate analysis of Kashigar et al,49 only the calcar-TAD an SHS with TSP.
was found to be a statistically significant predictor of fail- Basicervical fracture. True basicervical fractures are uncom-
ure and although the authors concluded that inferior place- mon and, although extracapsular, have similar rotational
ment conferred benefit, the reduction of the fracture was instability to those occurring more medially in the femoral
classified as poor in almost half of the 77 patients at a mean neck. A simple two-part basicervical fracture requires
follow-up of 408 days (81 days to 4.9 years). This, there- reduction with direct cortical contact, and stable, com-
fore, confounded the suggestion that the position of the pressed fixation. A de-rotation screw may offer increased
screw was predictive of the outcome, as varus mal-reduc- protection against rotational loss of reduction. A commi-
tion was also significantly associated with failure. nuted fracture with basicervical extension should be treated

VOL. 99-B, No. 1, JANUARY 2017


as a comminuted, unstable intertrochanteric fracture with 11. Marmor M, Liddle K, Buckley J, Matityahu A. Effect of varus and valgus align-
ment on implant loading after proximal femur fracture fixation. Eur J Orthop Surg
an intramedullary device. Traumatol 2016;26:379–383.
The role of arthroplasty. Certain unstable intertrochanteric 12. Marmor M, Liddle K, Pekmezci M, Buckley J, Matityahu A. The effect of frac-
fractures of the hip can be treated by arthroplasty. Indica- ture pattern stability on implant loading in OTA type 31-A2 proximal femur fractures.
J Orthop Trauma 2013;27:683–689.
tions include existing arthritis, osteonecrosis of the femoral
13. No authors listed. AO/OTA Fracture and Dislocation Classification. https://
head, poor quality of bone or complications following
internal fixation.60 There is limited evidence for the role of materials/classifications/Pages/ao-ota-classification.aspx (date last accessed 17
November 2016).
arthroplasty in treating unstable intertrochanteric frac-
14. Jin WJ, Dai LY, Cui YM, et al. Reliability of classification systems for intertrochan-
tures, with benefits including early mobilisation.60 The sur- teric fractures of the proximal femur in experienced orthopaedic surgeons. Injury
gery is technically challenging and should be undertaken by 2005;36:858–861.
an experienced arthroplasty surgeon. 15. Lorich DG, Geller DS, Nielson JH. Osteoporotic pertrochanteric hip fractures:
management and current controversies. Instr Course Lect 2004;53:441–454.
In conclusion, decision-making in the management of
16. Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the
intertrochanteric fractures requires a thorough understand- elderly. J Am Acad Orthop Surg 2004;12:179–190.
ing of the stability of the fracture and the implants which 17. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails
are available. More evidence on functional outcomes is versus extramedullary implants for extracapsular hip fractures in adults. Cochrane
Database of Syst Rev 2010;CD000093.
needed, especially in higher-functioning patients. It remains 18. Swart E, Makhni EC, Macaulay W, Rosenwasser MP, Bozic KJ. Cost-effective-
of critical importance to pay careful attention to the quality ness analysis of fixation options for intertrochanteric hip fractures. J Bone Joint Surg
[Am] 2014;96:1612–1620.
of the reduction and central and deep positioning of the
19. Krigbaum H, Takemoto S, Kim HT, Kuo AC. Costs and Complications of Short Ver-
screw or blade, regardless of implant. sus Long Cephalomedullary Nailing of OTA 31-A2 Proximal Femur Fractures in U.S.
Veterans. J Orthop Trauma 2016;30:125–129.
Take home message: 20. Bohl DD, Basques BA, Golinvaux NS, et al. Extramedullary compared with
intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of
There is conflicting evidence about the choice of implant in the 4432 procedures from the ACS NSQIP database. J Bone Joint Surg [Am]
treatment of intertrochanteric fractures of the hip, but assess- 2014;96:1871–1877.
ing the stability of the fracture allows one to choose between fixation 21. Lindvall E, Ghaffar S, Martirosian A, Husak L. Short vs Long Intramedullary Nails
in the Treatment of Pertrochanteric Hip Fractures. J Orthop Trauma 2016;30:119–124.
using a SHS or an intramedullary device.
22. Bhandari M, Schemitsch E, Jönsson A, Zlowodzki M, Haidukewych GJ.
Author contributions: Gamma nails revisited: gamma nails versus compression hip screws in the manage-
A. R. Socci: Primary researcher and writer. ment of intertrochanteric fractures of the hip: a meta-analysis. J Orthop Trauma
N. E. Casemyr: Researched and wrote significant portion of introduction, Edit- 2009;23:460–464.
ing and revising. 23. Basques BA, Bohl DD, Golinvaux NS, et al. Postoperative length of stay and 30-
M. P. Leslie: Wrote a section on technical aspects of reduction which was not day readmission after geriatric hip fracture: an analysis of 8434 patients. J Orthop
included, Participated in revision process. Trauma 2015;29:115–120.
M. R. Baumgaertner: Provided necessary oversight and guidance, Focused the
work on the most relevant references, concepts and controversies, Heavily 24. Liu P, Wu X, Shi H, et al. Intramedullary versus extramedullary fixation in the man-
involved in editing and revision. agement of subtrochanteric femur fractures: a meta-analysis. Clin Interv Aging
No benefits in any form have been received or will be received from a commer-
25. Utrilla AL, Reig JS, Muñoz FM, Tufanisco CB. Trochanteric gamma nail and com-
cial party related directly or indirectly to the subject of this article.
pression hip screw for trochanteric fractures: a randomized, prospective, comparative
This article was primary edited by P. Page and first proof edited by J. Scott. study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma
26. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochan-
References teric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A
1. No authors listed. Centers for Disease Control and Prevention: Hip Fractures randomised study comparing post-operative rehabilitation. J Bone Joint Surg [Br]
Among Older Adults. 2005;87-B:76–81.
ipfx.html (date last accessed 16 November 2016). 27. Hardy DC, Descamps PY, Krallis P, et al. Use of an intramedullary hip-screw com-
2. No authors listed. International Osteoporosis Foundation: Hip Fracture. https:// pared with a compression hip-screw with a plate for intertrochanteric femoral frac- (date last accessed 16 Novem- tures. A prospective, randomized study of one hundred patients. J Bone Joint Surg
ber 2016). [Am] 1998;80-A:618–630.
28. Ahrengart L, Törnkvist H, Fornander P, et al. A randomized study of the compres-
3. Chen F, Wang Z, Bhattacharyya T. Convergence of outcomes for hip fracture fixa- sion hip screw and Gamma nail in 426 fractures. Clin Orthop Relat Res 2002;401:209–
tion by nails and plates. Clin Orthop Relat Res 2012;471:1349–1355. 222.
4. No authors listed. American Academy of Orthopaedic Surgeons: Management of 29. Reindl R, Harvey EJ, Berry GK, Rahme E; Canadian Orthopaedic Trauma Soci-
Hip Fractures in the Elderly. (date last ety (COTS). Intramedullary Versus Extramedullary Fixation for Unstable Intertrochan-
accessed 16 November 2016). teric Fractures: A Prospective Randomized Controlled Trial. J Bone Joint Surg [Am]
5. Roberts KC, Brox WT, Jevsevar DS, Sevarino K. Management of hip fractures in
the elderly. J Am Acad Orthop Surg 2015;23:131–137. 30. Kleweno C, Morgan J, Redshaw J, et al. Short versus long cephalomedullary
nails for the treatment of intertrochanteric hip fractures in patients older than 65
6. Griffen JB. The calcar redefined. Clin Orthop Relat Res 1982;164:211–214. years. J Orthop Trauma 2014;28:391–397.
7. Browner BD, Jupiter JB, Krettek C, Anderson PA. Intertrochanteric Hip Frac- 31. Boone C, Carlberg KN, Koueiter DM, et al. Short versus long intramedullary nails
tures. In: Skeletal Trauma: Basic Science, Management, and Reconstruction. Amster- for treatment of intertrochanteric femur fractures (OTA 31-A1 and A2). J Orthop
dam: Elsevier, 2015:1683–1720. Trauma 2014;28:96–100.
8. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P, Hip Fracture Study Group. 32. Kanakaris NK, Tosounidis TH, Giannoudis PV. Nailing intertrochanteric hip frac-
Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important tures: short versus long; locked versus nonlocked. J Orthop Trauma 2015;29:S10–S16.
predictor of a reoperation. J Bone Joint Surg [Am] 2007;89-A:470–475. 33. Bridle SH, Patel AD, Bircher M, et al. Fixation of intertrochanteric fractures of the
femur. A randomised prospective comparison of the gamma nail and the dynamic hip
9. Im GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. J Orthop screw. J Bone Joint Surg [Br] 1991;73-B:330–334.
Trauma 2005;19:5–9.
34. Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the
10. Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res dynamic hip screw and the gamma locking nail. J Bone Joint Surg [Br] 1993;75-B:789–
1980;146:53–61. 793.



35. Robinson CM, Adams CI, Craig M, et al. Implant-related fractures of the femur fol- 49. Kashigar A, Vincent A, Gunton MJ, et al. Predictors of failure for cephalomedul-
lowing hip fracture surgery. J Bone Joint Surg [Am] 2002;84-A:1116–1122. lary nailing of proximal femoral fractures. Bone Joint J 2014;96-B:1029–1034.
36. O’Neill F, Condon F, McGloughlin T, et al. Dynamic hip screw versus DHS blade: 50. De Bruijn K, den Hartog D, Tuinebreijer W, Roukema G. Reliability of predictors
a biomechanical comparison of the fixation achieved by each implant in bone. J Bone for screw cutout in intertrochanteric hip fractures. J Bone Joint Surg [Am] 2012;94-
Joint Surg [Br] 2011;93-B:616–621. A:1266–1272.
37. Fang C, Lau TW, Wong TM, Lee HL, Leung F. Sliding hip screw versus sliding hel- 51. Varela-Egocheaga JR, Iglesias-Colao R, Suárez-Suárez MA, et al. Minimally
ical blade for intertrochanteric fractures: a propensity score-matched case control invasive osteosynthesis in stable trochanteric fractures: a comparative study
study. Bone Joint J 2015;97-B:398–404. between Gotfried percutaneous compression plate and Gamma 3 intramedullary nail.
38. Huang X, Leung F, Liu M, et al. Is helical blade superior to screw design in terms of Arch Orthop Trauma Surg 2009;129:1401–1407.
cut-out rate for elderly trochanteric fractures? A meta-analysis of randomized con- 52. Babst R, Renner N, Biedermann M, et al. Clinical results using the trochanter sta-
trolled trials. Eur J Orthop Surg Traumatol 2014;24:1461–1468. bilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal
39. Stern R, Lübbeke A, Suva D, Miozzari H, Hoffmeyer P. Prospective randomised fixation of selected unstable intertrochanteric fractures. J Orthop Trauma
study comparing screw versus helical blade in the treatment of low-energy trochan- 1998;12:392–399.
teric fractures. Int Orthop 2011;35:1855–1861. 53. Madsen JE, Naess L, Aune AK, et al. Dynamic hip screw with trochanteric stabi-
40. Frei HC, Hotz T, Cadosch D, Rudin M, Käch K. Central head perforation, or “cut lizing plate in the treatment of unstable proximal femoral fractures: a comparative
through,” caused by the helical blade of the proximal femoral nail antirotation. J study with the Gamma nail and compression hip screw. J Orthop Trauma
Orthop Trauma 2012;26:102–107. 1998;12:241–248.
41. Brunner A, Jöckel JA, Babst R. The PFNA proximal femur nail in treatment of 54. Miedel R, Ponzer S, Törnkvist H, Söderqvist A, Tidermark J. The standard
unstable proximal femur fractures--3 cases of postoperative perforation of the helical Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric
blade into the hip joint. J Orthop Trauma 2008;22:731–736. fractures. A randomised, controlled trial. J Bone Joint Surg [Br] 2005;87-B:68–75.
42. Kubiak EN, Bong M, Park SS, et al. Intramedullary fixation of unstable intertro- 55. Sadowski C, Lübbeke A, Saudan M, et al. Treatment of reverse oblique and trans-
chanteric hip fractures: one or two lag screws. J Orthop Trauma 2004;18:12–17. verse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees
43. Kouvidis G, Sakellariou VI, Mavrogenis AF, et al. Dual lag screw cephalomedul- screw-plate: a prospective, randomized study. J Bone Joint Surg [Am] 2002;84-
lary nail versus the classic sliding hip screw for the stabilization of intertrochanteric A:372–381.
fractures. A prospective randomized study. Strategies Trauma Limb Reconstr 56. Schipper IB, Steyerberg EW, Castelein RM, et al. Treatment of unstable trochan-
2012;7:155–162. teric fractures randomised comparison of the gamma nail and the proximal femoral
44. Norris R, Bhattacharjee D, Parker MJ. Occurrence of secondary fracture around nail. J Bone Joint Surg [Br]2004;86-B:86–94.
intramedullary nails used for trochanteric hip fractures: a systematic review of 13,568 57. Matre K, Havelin LI, Gjertsen JE, et al. Sliding hip screw versus IM nail in reverse
patients. Injury 2012;43:706–711. oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the
45. Streubel PN, Moustoukas M, Obremskey WT. Locked plating versus cepha- Norwegian Hip Fracture Register. Injury 2013;44:735–742.
lomedullary nailing of unstable intertrochanteric femur fractures. Eur J Orthop Surg 58. Kuzyk PRT, Lobo J, Whelan D, et al. Biomechanical evaluation of extramedullary
Traumatol 2016;26:385–390. versus intramedullary fixation for reverse obliquity intertrochanteric fractures. J
46. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex Orthop Trauma 2009;23:31–38.
distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone 59. Matre K, Vinje T, Havelin LI, et al. TRIGEN INTERTAN intramedullary nail versus
Joint Surg [Am] 1995;77-A:1058–1064.
sliding hip screw: a prospective, randomized multicenter study on pain, function, and
47. Parker MJ. Cutting-out of the dynamic hip screw related to its position. J Bone Joint complications in 684 patients with an intertrochanteric or subtrochanteric fracture
Surg [Br] 1992;74-B:625. and one year of follow-up. J Bone Joint Surg [Am] 2013;95:200–208.
48. Kuzyk PRT, Zdero R, Shah S, et al. Femoral head lag screw position for cepha- 60. Mäkinen TJ, Gunton M, Fichman SG, et al. Arthroplasty for Pertrochanteric Hip
lomedullary nails: a biomechanical analysis. J Orthop Trauma 2012;26:414–421. Fractures. Orthop Clin North Am 2015;46:433–444.

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