n the cutting edge Case Reports Maintaining the Integrity of the Lateral Trochanteric Wall 306 Copyright SLACK Incorporated

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1 Section Editor: Bennie G.P. Lindeque, MD Use of Auxiliary Locking Plates for the Treatment of Unstable Pertrochanteric Femur Fractures Ho Hyun Yun, MD; Yong In Lee, MD; Kyoung Ho Kim, MD; Se Hyeok Yun, MD Abstract: Pertrochanteric femur fractures are successfully treated by orthopedic surgeons worldwide, but maintaining the reduction status or fixation is sometimes difficult in unstable cases in elderly patients. Several biomechanical advantages have been reported in locking plates when compared with conventional plates; locking plates provide angular and axial stability, better rigidity, and no toggling, and they preserve periosteal blood supply. The authors describe the use of auxiliary locking plates in unstable pertrochanteric femur fractures in elderly patients. Mini locking plates are simple, straightforward, and versatile enough to be used in elderly patients. [Orthopedics. 2015; 38(5): ] Although pertrochanteric femur fractures are successfully treated by orthopedic surgeons worldwide, maintaining the reduction status or fixation is sometimes difficult in unstable cases in elderly patients. In contrast to controlled fracture impaction, fracture collapse is a major cause of internal fixation failure in these fractures, and maintaining the integrity plays a key role in the prevention of fracture collapse. 1 When The authors are from the Department of Orthopaedic Surgery, Seoul Veterans Hospital, Seoul, South Korea. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Ho Hyun Yun, MD, Department of Orthopaedic Surgery, Seoul Veterans Hospital, #6-2 Dunchon-dong, Gangdong-gu, Seoul, Korea (3188yun@naver.com). Received: December 3, 2014; Accepted: February 18, doi: / total hip arthroplasty (THA) is performed for the treatment of unstable pertrochanteric femur fractures in elderly patients, fixation is essential because malunion or nonunion may cause complications, including pain, abductor muscle weakness, limping gait, and increased dislocation risk. 2 There are several techniques for maintaining the integrity when internal fixations are performed for the treatment of pertrochanteric hip fractures. 3-5 There are also several fixation methods for the greater trochanter during THA performed for the treatment of unstable pertrochanteric femur fractures. 2,6-8 Several biomechanical advantages have been reported in locking plates (LPs) when compared with conventional plates 9 ; LPs provides angular and axial stability, better rigidity, and no toggling, and they preserve periosteal blood supply. In a biomechanical study, LPs improved the primary stability of greater trochanter fractures over fixation with cable cerclages. 10 The 3.5-mm LPs can successfully reattach a greater trochanter nonunion with a failed cable grip or plate device, especially if bone-to-bone apposition is achieved intraoperatively. 11,12 This article reports the use of auxiliary LPs to maintain the integrity of the lateral trochanteric wall, based on the concept of reduction plating, 13,14 and to fix the greater trochanter during THA in unstable pertrochanteric femur fractures in elderly patients. Materials and Methods Between January 2011 and February 2012, a total of 22 patients (22 hips) with a mean age of 78.8±5.9 years (range, years) underwent surgery and were enrolled in this study. All patients were followed for a minimum of 1 year. The male/female ratio was 14/8. The authors used mini LPs (LCP Compact MAY 2015 Volume 38 Number 5 305

2 ability had returned to prefracture level. Radiographically, the fracture was united (Figure 1H). Figure 1: Plain radiographs (A-B) and 3-dimensional reconstructed computed tomography scans (C-D) showing an OTA/AO 31A3.2 intertrochanteric femur fracture with broken lateral trochanter. Fluoroscopic image showing a persistent fracture gap with varus reduction (E). Intraoperative photograph showing a visible fracture gap (F). The lateral trochanteric wall was reduced and provisionally fixed with two 2.0-mm locking plates along the anterolateral and posterolateral cortex, considering the insertion site of the lag screw (G). One-year postoperative radiograph showing the stable implant with union (H). Hand; DePuy Synthes, West Chester, Pennsylvania) in all patients. In 6 patients, mini LPs were used to maintain the integrity of the lateral trochanteric wall before lag screws were inserted during proximal femoral nailing. In the remaining 16 patients, mini LPs were used to fix the greater trochanter during bipolar hemiarthroplasty. This study was approved by the institutional review board, and all patients provided informed consent. Case Reports Maintaining the Integrity of the Lateral Trochanteric Wall A 78-year-old man presented with right hip pain that began after a fall. Based on plain radiographs and 3-dimensional reconstructed computed tomography (CT) scans (Figures 1A-D), he was diagnosed with an OTA/AO 31A3.2 intertrochanteric femur fracture with a broken lateral trochanteric wall. Intramedullary hip nailing was planned, and due to the fracture pattern, certain technical problems during lag screw insertion were predicted. Reduction was performed with the help of a fracture table, and a persistent fracture gap with varus reduction was seen (Figures 1E-F). The lateral trochanteric wall was reduced and provisionally fixed with two 2.0-mm mini LPs before insertion of the intramedullary hip nail (Figure 1G), considering the insertion site of the lag screw. Soft tissue preservation was attempted wherever possible because nonunion is a known consequence if soft tissue preservation is violated. 13,15 Two locking head screws (10-14 mm long) were fixed in both the proximal and distal segments. Then, an intramedullary hip nail (Gamma3; Stryker, Mahwah, New Jersey) was passed through the fracture site. Finally, a lag screw was inserted between the LPs. Tolerable weight bearing was allowed starting 2 days postoperatively. One year postoperatively, the patient had no pain, and his walking Fixation of the Greater Trochanter An 83-year-old man presented with severe right hip pain that had developed after a fall. Based on plain radiographs and 3-dimensional reconstructed CT scans (Figure 2A), he was diagnosed with an OTA/AO 31A2.2 intertrochanteric fracture. The fracture was comminuted with displaced trochanteric fragments. Bipolar hemiarthroplasty was planned using a posterolateral approach. After femoral implantation with a cemented femoral stem (Logica, Lima, Italy), a plan was made to fix the greater trochanteric fragment with two 2.4-mm mini LPs. Following exposure of the proximal femur, the soft tissue around the greater trochanteric fragment and femoral bed was stripped only from the adjoining margins. Preservation of soft tissue was attempted whenever possible. The greater trochanteric fragment and the femoral bed were cleaned of all debris to expose cancellous bone surfaces. The provisional reduction was maintained using a clamp with the hip in abduction and internal rotation. Reduction was maintained with 2 precontoured 2.4-mm mini LPs inserted perpendicular to the fracture plane, which ran from the posterosuperior to the posteroinferior direction (Figure 2B). Two locking head screws (16 to 20 mm 306 Copyright SLACK Incorporated

3 long) were fixed in both the proximal and distal segments. Postoperatively, the patient was mobilized immediately with toe-touch weight bearing, and then progressive weight bearing was allowed. Two years postoperatively, he had no pain, and his walking ability had returned to pre-fracture level. Radiographically, the femoral component was stable and the trochanteric fragments were united (Figure 2C). Results Average time to union in 20 cases was 15.5±3.5 weeks (range, weeks) (Table). All delayed unions healed spontaneously, with minor trochanteric migration of less than 5 mm. There were 3 nonunions. All patients with nonunions refused further treatment. There were 3 cases of plate or screw failure (Table). All complications occurred in cases in which the segments were fixed with 2.0-mm mini LPs. Discussion The authors used mini LPs as a provisional fixation device for maintenance of the lateral trochanteric wall during intramedullary hip nailing or as a definitive fixation device for greater trochanteric fragments in unstable pertrochanteric femur fractures in elderly patients. Mini LPs are malleable and easily contoured on the lateral surface of the proximal femur, and successful results using mini LPs are possible even when treating the difficult fractures reported here. Figure 2: Plain radiograph (top) and 3-dimensional reconstructed computed tomography scans (bottom) showing OTA/AO 31A2.2 intertrochanteric femur fracture with severe comminution (A). Initial postoperative radiograph showing a fixed greater trochanter with two 2.4-mm mini locking plates (B). Two-year postoperative radiographs showing a stable implant with union (C). Maintaining the integrity is well known as an important predictor of reoperation with the use of a sliding hip screw, 16 and the lateral trochanteric wall is usually intact preoperatively but becomes fractured intraoperatively. The incidence of intraoperative lateral trochanteric wall fracture of OTA/AO 31A1 and A2 intertrochanteric femur fractures during intramedullary hip nailing is as high as that when using sliding hip screws, 5,17 but the presence of intraoperative lateral trochanteric wall fractures in instances of intramedullary hip nailing did not increase the rate of reoperation Intramedullary hip nailing can effectively limit the instability created by intraoperative lateral trochanteric wall fractures in OTA/AO 31A1 and A2 intertrochanteric femoral fractures. 16 However, is it unclear whether the benefit conferred by the strut function of intramedullary hip nailing would apply in OTA/AO 31A3 intertrochanteric femoral fractures where the lateral femoral wall is already broken and displaced at the time of injury. Reduction plating by applying unicortical, small-fragment plates has been used to maintain the reduction until definitive fixation can be applied. 13 One-third tubular plates and dynamic compression plates have been successfully used for provisional fixation as a reduction plate in the management of comminuted metadiaphyseal and diaphyseal fractures and complex periarticular fractures. 13,14 Several biomechanical advantages have been reported for LPs when compared with conventional plates. 9 The current authors suggest that reduction plating with mini LPs for the fixation of the lateral trochanteric wall in OTA/AO 31A3 intertrochanteric femur fractures in elderly patients may be helpful for maintenance of the lateral trochanteric wall during intramedullary hip nailing and the prevention of eccentric lag screw placement, which is frequently either too anterior or too superior in comminuted fractures 21 through the lateral trochanteric wall. MAY 2015 Volume 38 Number 5 307

4 Patient No./ Sex/Age, y OTA/AO Classification Fracture has previously been thought to have little effect on the overall outcome following THA, 22 but several studies suggest otherwise. 2,6-8 Regardless of the etiology, nonunion can result in significant pain, Trendelenburg gait, and functional limitations, and additional surgery to reattach the trochanter may be required. 23,24 There are several methods for fixation in THA performed for unstable pertrochanteric femur fractures. 2,6-8 Heavy suture is Table Patient Demographics Treatment Plate Size, mm inexpensive and easy to use and has the added advantage of additional pullout strength by being inserted into either bone or tendon. However, compared with repair of trochanteric slide osteotomies with a suture technique, 25 fixation with heavy sutures poses a challenge in THA performed for pertrochanteric femur fractures in elderly patients who have osteoporotic fragments with a paper-thin cortical bone and may have the damaged vastus lateralis continuity with the trochanter, which results in Time to Union, wk 1/M/78 A3-1 Nailing Complication 2/M/67 A3-2 Nailing Plate breakage 3/M/83 A3-3 Nailing 2.0 Nonunion 4/F/76 A3-2 Nailing /F/87 A1-2 Nailing /M/87 A3-3 Nailing /M/82 A2-2 Bipolar /M/78 A2-3 Bipolar /M/84 A2-2 Bipolar /M/77 A2-2 Bipolar Screw pullout 11/M/84 A2-2 Bipolar 2.0 Nonunion 12/M/71 A2-2 Bipolar /F/77 A2-3 Bipolar /M/65 A2-2 Bipolar /F/76 A2-2 Bipolar /M/82 A2-2 Bipolar /M/81 A2-2 Bipolar /M/79 A2-2 Bipolar /F/82 A2-2 Bipolar /F/79 A2-2 Bipolar Plate pullout 21/F/71 A2-2 Bipolar /M/80 A2-2 Bipolar higher shear forces being generated across the fracture area. Cerclage 7 and tension-band wiring, 6 which have been traditionally used, are not always possible because the wire may cut through the thin cortical bone in elderly patients during tightening. 2 Wiring through cannulated screws improves on the weakness of fixation with screws alone. 2 However, this technique can be difficult when dealing with large trochanteric fragments involving the anterior aspect of the greater trochanter. A cable grip and plate system is a good option when the lateral trochanteric wall is involved. 8 However, implants are relatively bulky and therefore problematic. A trochanteric bolt and washer system can be used in a specific built-in femoral stem only and is associated with complications, including nonunion, trochanteric migration, hip instability, and bursitis. 7 The 3.5-mm LPs can successfully reattach nonunion of the greater trochanter with a failed cable grip or plate device if bone-to-bone apposition is achieved intraoperatively. 11,12 When compared with conventional plates, LPs have several biomechanical advantages, 9 and LPs improved the primary stability of greater trochanter fractures over fixation with cable cerclages in a biomechanical study. 10 Moreover, mini LPs are malleable and easily contoured with the surface of the greater trochanter. The disadvantage of this technique lies in the difficulty of dealing with severe comminuted cases involving the greater trochanter because there is inadequate bone to anchor the screws. In that situation, wiring may be necessary to hold the greater trochanteric fragments. In other circumstances, mini LPs may be a good solution to fix the greater trochanter, especially in elderly patients. There are several limitations to this study. First, the study retrospectively analyzed a small number of cases. Second, the study did not have a control group. Finally, the authors technique has not been evaluated, and it has not been compared with existing meth- 308 Copyright SLACK Incorporated

5 ods. Further studies are required to confirm whether LPs can be useful in pertrochanteric femur fractures compared with existing methods. Conclusion The authors describe the use of auxiliary LPs in unstable pertrochanteric femur fractures in elderly patients. Mini LPs are simple, straightforward, and versatile enough to be used in elderly patients. Accurate bone-to-bone apposition and soft tissue preservation should be achieved intraoperatively. However, long-term studies with larger numbers of patients are required to address late complications and whether the fixations are durable enough for long-surviving patients. References 1. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res. 2004; 425: Im GI, Lee SH. Wiring through cannulated screws for the fixation of greater trochanter in arthroplasties performed for peritrochanteric fractures. J Arthroplasty. 2006; 21: Macheras GA, Koutsostathis SD, Galanakos S, Kateros K, Papadakis SA. Does PFNA II avoid lateral cortex impingement for unstable peritrochanteric fractures? Clin Orthop Relat Res. 2012; 470: Gupta RK, Sangwan K, Kamboj P, Punia SS, Walecha P. Unstable trochanteric fractures: the role of lateral wall reconstruction. Int Orthop. 2010; 34: Knobe M, Drescher W, Heussen N, Sellei RM, Pape HC. Is helical blade nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures? Clin Orthop Relat Res. 2012; 470: Grimsrud C, Monzon RJ, Richman J, Ries MD. Cemented hip arthroplasty with a novel cerclage cable technique for unstable intertrochanteric hip fractures. J Arthroplasty. 2005; 20: Chilvers M, Vejvoda H, Trammell R, Allan DG. Trochanteric fixation in total hip arthroplasty using the S-ROM bolt and washer. J Arthroplasty. 2002; 17: Takahira N, Itoman M, Uchiyama K, Takasaki S, Fukushima K. Reattachment of the greater trochanter in total hip arthroplasty: the pin-sleeve system compared with the Dall-Miles cable grip system. Int Orthop. 2010; 34: Buijze GA, Blankevoort L, Tuijthof GJ, Sierevelt IN, Kloen P. Biomechanical evaluation of fixation of comminuted olecranon fractures: one-third tubular versus locking compression plating. Arch Orthop Trauma Surg. 2010; 130: Cloutier LP, Laflamme GY, Petit Y. Biomechanical analysis of trochanteric fracture fixations using a Y-shaped locking plate. J Orthop Trauma. 2013; 27: Laflamme GY, Leduc S, Petit Y. Reattachment of complex femoral greater trochanteric nonunions with dual locking plates. J Arthroplasty. 2012; 27: McGrory BJ, Lucas R. The use of locking plates for greater trochanteric fixation. Orthopedics. 2009; 32: Archdeacon MT, Wyrick JD. Reduction plating for provisional fracture fixation. J Orthop Trauma. 2006; 20: Oh JK, Sahu D, Park JW, Oh CW, Hwang JH. Use of 2.0 mini plate system as reduction plate. Arch Orthop Trauma Surg. 2010; 130: Oh JK, Sahu D, Park JW, Oh CW, Hwang JH. Use of 2.0 mini plate system as reduction plate. Arch Orthop Trauma Surg. 2013; 130: Palm H, Jacobsen S, Sonne- Holm S, Gebuhr P. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007; 89: Boopalan PR, Oh JK, Kim TY, Oh CW, Cho JW, Shon WY. Incidence and radiologic outcome of intraoperative lateral wall fractures in OTA 31A1 and A2 fractures treated with cephalomedullary nailing. J Orthop Trauma. 2012; 26: Biber R, Gruninger S, Singler K, Sieber CC, Bail HJ. Is proximal femoral nailing a good procedure for teaching in orthogeriatrics? Arch Orthop Trauma Surg. 2012; 132: Kokoroghiannis C, Aktselis I, Deligeorgis A, Fragkomichalos E, Papadimas D, Pappadas I. Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures: a review. Injury. 2012; 43: Fogagnolo F, Kfuri M Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg. 2004; 124: Garg B, Malhotra R, Jayaswal A, Kotwal PP. Integrity of the lateral femoral wall in intertrochanteric hip fractures. J Bone Joint Surg Am. 2007; 89: Pritchett JW. Fracture of the greater trochanter after hip replacement. Clin Orthop Relat Res. 2001; 390: Brun OC, Maansson L. Fractures following total hip replacement. Hip Int. 2013; 23: Capello WN, Feinberg JR. Trochanteric excision following persistent nonunion of the greater trochanter. Orthopedics. 2008; 31: Plausinis D, Speirs AD, Masri BA, Garbuz DS, Duncan CP, Oxland TR. Fixation of trochanteric slide osteotomies: a biomechanical study. Clin Biomech (Bristol, Avon). 2003; 18: MAY 2015 Volume 38 Number 5 309