INTERTROCHANTERIC
`
`FEMORAL
`
`FRACTURES
`
`MECHANICAL
`
`FAILURE
`
`AFTER
`
`INTERNAL
`
`FIXATION
`
`T. R. C. DAVIS,
`
`J. L. SHER,
`
`A. HORSMAN,
`
`M.
`
`SIMPSON,
`
`B. B. PORTER,
`
`R. G. CHECKETFS
`
`From
`
`Dryburn
`
`Hospital,
`
`Durham,
`
`Sunderland
`
`District
`
`General
`
`Hospital
`
`and
`
`The General
`
`Infirmary,
`
`Leeds
`
`study we assessed
`In a prospective
`which
`had been
`femoral
`fractures
`internally
`rate
`of mechanical
`failure
`The overall
`cause
`in three-quarters
`of
`the
`instances.
`the
`than
`those
`placed
`(7%).
`(27%)
`centrally
`often
`but age, walking
`reduction,
`fracture
`abifity
`and
`had no significant
`influence.
`indices)
`conclude
`that
`these
`fractures
`We
`the implant
`is placed
`centrally
`within
`
`the
`
`of 230
`in a series
`of mechanical
`causes
`intertrochantenc
`failure
`fixed with
`either
`a sliding
`hip screw or a Kfintscher
`Y-nail.
`16.5%;
`cutting-out
`of
`the implant
`from the femoral
`head was
`was
`Implants
`placed
`posteriorly
`in the
`femoral
`head
`cut
`out more
`by the
`of
`the
`The
`cot-out
`rate
`was
`also
`determined
`quality
`by the Singh
`grade
`and metacarpal
`bone
`density
`(assessed
`
`be
`should
`the femoral
`
`reduced
`head.
`
`as accurately
`
`as possible
`
`and it
`
`is imperative
`
`that
`
`of
`position
`by the
`is
`location
`ideal
`the
`of
`placement
`(Muiholland
`authors
`posterior
`recommend
`1979).
`Zimmerman
`of a sliding
`the
`tip
`the
`articular
`surface,
`that
`it
`is placed
`within
`
`in
`
`is
`
`al
`
`implant
`the
`controversial
`implant
`and Gunn
`placement
`Jensen
`et
`screw
`should
`while
`Kyle
`10 mm of
`
`and
`that
`from
`
`fractures
`intertrochanteric
`of unstable
`fixation
`Internal
`5% to 10% have
`rates
`of
`always
`successful.
`Failure
`is not
`screw
`devices
`(Jensen,
`reported
`with
`sliding
`been
`T#{248}ndevoldand Mossing
`1978 ; Kyle,
`and
`Gustilo
`Premer
`; Bannister
`1979
`; Wolfgang,
`Bryant
`and O’Neill
`1982
`and
`Gibson
`1983).
`Cutting-out
`of
`the
`implant
`from
`the
`was
`femoral
`head
`the most
`common
`cause
`of mechanical
`incidence
`failure.
`The
`ofcutting-out
`is determined
`by the
`fracture
`subtype
`(Jensen
`1980),
`quality
`ofthe
`fracture
`reduction
`and
`the
`type
`implant
`(Jensen,
`Sonne-Holm
`of
`bone
`and
`T#{248}ndevold 1980).
`Reduced
`density
`may
`also
`a relevant
`factor
`(Laros
`and Moore
`1974).
`Although
`a number
`of authors
`believe
`
`be
`
`that
`
`the
`
`cut-
`
`the
`
`with
`density
`
`is determined
`rate
`out
`the
`femoral
`head,
`the
`(DeLee
`1984).
`Central
`recommended
`by some
`1972)
`while
`others
`(Laskin,
`Gruber
`(1978)
`recommend
`be
`at
`least
`10 mm
`et
`al
`(1979)
`advocate
`this
`surface.
`In our
`investigated
`patients
`bone
`
`causes
`
`the
`study
`prospectively
`particular
`and
`the
`
`of mechanical
`in
`a
`consecutive
`attention
`to the
`roles
`position
`the
`fixation
`
`were
`of
`
`failure
`series
`reduced
`of
`device.
`
`of
`
`T. R. C. Davis,
`FRCS,
`University
`Department
`Newcastle
`upon
`Tyne
`
`Orthopaedic
`Senior
`of Orthopaedics,
`4LP,
`England.
`
`NE1
`
`Registrar
`Royal
`
`Victoria
`
`Infirmary,
`
`PATIENTS
`
`AND METHODS
`
`District
`from
`age
`
`and Dryburn
`Hospital
`General
`1985,
`every
`1983
`to May
`June
`50 with
`an
`intertrochanteric
`of
`provided
`that
`they were
`considered
`
`J. L. Sher,
`Ashington
`England.
`
`A. Horsman,
`M. Simpson,
`MRC
`Bone
`The General
`
`FRCS,
`General
`
`Consultant
`Hospital,
`
`Surgeon
`West View, Ashington,
`
`Northumberland,
`
`PhD,
`MA,
`Senior
`BSc,
`Mineralisation
`Infirmary,
`
`Senior
`Research
`Group,
`LS1
`
`Leeds
`
`Officer
`
`Scientific
`Officer
`Department
`3EX,
`England.
`
`of Medical
`
`Physics,
`
`FRCS,
`B. B. Porter,
`Dryburn
`Hospital,
`
`Consultant
`Durham,
`
`Surgeon
`England.
`
`R. G. Checketts,
`Sunderland
`District
`and Wear
`SR4
`7TP,
`
`Consultant
`FRCS,
`General
`Hospital,
`England.
`
`Surgeon
`Kayll
`
`Road,
`
`Sunderland,
`
`Tyne
`
`should
`
`be
`
`sent
`
`to Mr
`
`J .L. Sher.
`
`Society
`
`of Bone
`
`and
`
`Joint
`
`Surgery
`
`Editorial
`187
`$2.00
`1990;
`
`72-B:
`
`26-31.
`
`Correspondence
`© 1989
`British
`0301-620X/90/l
`JBoneJointSurg[Br]
`
`26
`
`At Sunderland
`Hospital,
`Durham
`patient
`over
`the
`fracture
`was
`included,
`fit
`for
`anaesthesia.
`intensification
`image
`Using
`Operative
`technique.
`near
`an
`as
`to
`reduction
`was
`performed
`displacement
`position
`possible.
`Medial
`osteotomies
`Hughston
`1967)
`or
`valgus
`performed.
`Williams
`1970)
`were
`not
`a sliding
`internally
`fixed with
`either
`Fig.
`1) or
`a K#{252}ntscher Y-nail
`(Fig.
`implant
`was
`determined
`pre-operatively
`
`as
`
`a closed
`anatomical
`and
`(Dimon
`and
`(Sarmiento
`was
`Each
`fracture
`hip
`screw
`(Richards
`2).
`The
`choice
`random
`
`of
`
`by
`
`THE JOURNAL
`
`OF BONE
`
`AND
`
`JOINT
`
`SURGERY
`
`ZIMMER 1042
`Page 1
`
`

`
`INTERTROCHA
`
`NTERIC
`
`FEMORAL
`
`FRACTURES
`
`27
`
`Fig.
`
`1
`
`AP
`
`and
`
`lateral
`
`radiographs
`
`of a sliding
`
`hip screw.
`
`Table
`
`II.
`
`Frequency
`
`of mechanical
`
`complications
`
`KBntscher
`Y-nail
`(n=116)
`
`12(2)’
`
`hip
`
`Sliding
`screw
`(n=1l4)
`
`17(3)’
`
`Total
`(n=230)
`
`29(5)’
`
`2
`
`1
`
`1
`
`1
`
`4
`
`0
`
`3
`
`5
`
`1
`
`Cutting-out
`
`Implant
`bending
`
`fracture
`
`or
`
`loosening
`Implant
`from femoral
`shaft
`
`Implant
`
`uncoupling
`
`‘cases
`
`with
`
`implant
`
`tip
`
`in joint
`
`space
`
`Table
`age,
`
`III.
`sex
`
`Frequency
`and mobility
`
`ofcutting-out,
`
`related
`
`to
`
`Age<80years
`Age>80years
`
`Male
`Female
`
`Pre-fracture
`Good
`Poor
`
`mobility
`
`Number
`
`l4of92
`lOofl33
`
`2of40
`22of185
`
`l7ofll5
`7ofllO
`
`Per
`
`cent
`
`15
`8
`
`5
`12
`
`15
`6
`
`the
`and
`
`K#{252}ntscher Y-
`Howat
`(1976).
`was
`encouraged
`
`aids,
`
`walking
`prefracture
`pre-operatively.
`was
`the
`patient
`able
`to walk
`
`if
`was
`
`allocation.
`as
`nail
`was
`Weight-bearing,
`after
`from
`48 hours
`Patient
`assessment.
`ability
`of
`each
`patient
`Walking
`ability
`was
`housebound
`and
`good
`outside
`or without
`with
`of
`Radiographs
`were
`right
`hand
`ofthe
`simple
`to make
`two
`trabecular
`state
`of
`the
`the
`Singh
`assessed
`using
`the
`and Maini
`1970)
`and
`was
`second
`metacarpal
`(Horsman
`cortical
`area
`ratio
`grading
`and
`metacarpal
`by one
`experienced
`observer
`outcome
`of
`the
`fracture
`pattern
`proximal
`were
`it was
`error
`separate
`The
`results
`cut-out
`of
`compared
`were
`matched
`ture
`mobility,
`failure.
`
`a
`of
`intermediate
`to
`allocated
`was
`minimised
`occasions
`for
`the
`with
`
`inserting
`for
`method
`The
`by Cuthbert
`described
`walking
`using
`operation.
`the
`The
`and
`age
`recorded
`were
`as
`poor
`classed
`or
`she
`he
`if
`aid.
`a walking
`contralateral
`patient’s
`the
`pre-operatively,
`obtained
`of
`bone
`estimations
`proximal
`the
`bone
`method
`(Singh,
`grading
`the
`cortical
`state
`by measurement
`assessed
`Kirby
`1972).
`and
`morphometry
`were
`not
`who
`(MS)
`did
`the
`When
`fixation.
`characteristics
`had
`femur
`two
`between
`consecutive
`an
`intermediate
`half-grade.
`film
`by
`assessing
`each
`two
`the
`using
`the mean
`of
`fixation
`patients
`where
`the
`were
`head
`(cut-out
`group)
`patients
`results
`40
`control
`of
`and
`sex,
`fracture
`subtype
`union
`occurred
`without
`
`in
`
`of
`
`and
`
`those
`femoral
`the
`age,
`for
`in whom
`
`the
`
`and
`hip
`used
`and
`The
`density.
`was
`femur
`Nagrath
`the
`bone
`of
`the
`of
`Singh
`The
`performed
`know
`trabecular
`which
`grades
`Observer
`two
`on
`results.
`device
`then
`who
`prefrac-
`fixation
`
`Singh
`
`Fig.
`
`2
`
`AP
`
`and
`
`lateral
`
`radiographs
`
`of a KOntscher
`
`Y-nail.
`
`I.
`Table
`trochanteric
`
`Incidence
`fracture
`
`and method
`
`of
`
`fixation
`
`of different
`
`types
`
`of
`
`Kuntscher
`Y-nail
`
`hip
`
`Sliding
`screw
`
`Total
`
`Number
`
`Per
`
`cent
`
`2-part
`displaced
`
`3-part
`lateral
`
`3-part
`medial
`
`Complex
`
`Associated
`subtrochanteric
`
`Basi-trochanteric
`
`22
`
`28
`
`18
`
`35
`
`9
`
`4
`
`Total
`
`116
`
`13
`
`22
`
`7
`
`56
`
`11
`
`5
`
`114
`
`15
`
`22
`
`11
`
`39
`
`9
`
`4
`
`35
`
`50
`
`25
`
`91
`
`20
`
`9
`
`230
`
`VOL.
`
`72-B, No.
`
`1, JANUARY
`
`1990
`
`ZIMMER 1042
`Page 2
`
`

`
`28
`
`T. R. C. DAVIS,
`
`J. L. SHER,
`
`A. HORSMAN,
`
`M. SIMPSON,
`
`B. B. PORTER,
`
`R. G. CHECKETTS
`
`2-part
`
`Displaced
`
`3-part,
`
`lateral
`
`fra(cid:1)i-ient
`
`3-part,
`
`medial
`
`fragment
`
`Complex
`
`(4-part)
`
`Associated
`
`Subtrochanteric
`
`Bas(cid:1)
`
`classification
`The
`fractures.
`
`of
`
`intertrochanteric
`
`femoral
`
`Fig.
`
`3
`
`Fig.
`
`4
`
`central
`superior,
`as
`classed
`(lateral
`radiograph)
`plane
`distance
`between
`The
`articular
`surface
`was
`
`inferior
`or
`anterior,
`as
`tip
`of
`the
`also measured
`
`the
`
`of
`
`was
`radiograph)
`sagittal
`and
`in the
`central
`or posterior.
`device
`and
`the
`nearest
`(Fig.
`4).
`patients,
`surviving
`of
`fractures
`the
`Radiographs
`postoperatively,
`3, 6, and
`12 months
`obtained
`at 6 weeks,
`The
`of
`fixation.
`used
`were
`to
`demonstrate
`any
`failure
`defined
`one-yearsurvival
`was
`61%.
`Failure
`offixation
`was
`as migration
`the
`device
`within
`the
`head
`; cutting-out
`of
`from the head
`; loosening,
`bending,
`fracture
`or uncoupling
`of
`the
`implant.
`Statistical
`analysis.
`chi-squared
`test
`
`Unless
`statistical
`
`otherwise,
`stated
`analyses.
`
`for
`
`we
`
`used
`
`the
`
`assessment
`The
`lateral
`diastasis;
`B,
`tip
`to the
`nearest
`
`of
`
`postoperative
`diastasis;
`articular
`
`cortex.
`
`radiographs.
`distance
`
`from
`
`C,
`
`AP
`
`A,
`implant
`
`RESULTS
`
`40 men
`including
`study,
`the
`entered
`patients
`230
`In all,
`years,
`and
`age was
`80.6
`Their
`average
`and
`190 women.
`in Table
`fracture
`is shown
`each
`type
`of
`the
`number
`with
`I. A total
`1 16 K#{252}ntscher Y-nails
`and
`1 14 sliding
`hip
`screws
`were
`inserted.
`The
`overall
`rate
`cutting-out
`of
`the
`and
`the
`cause
`in
`76%
`was
`mechanical
`failure
`were
`excluded
`further
`analysis.
`Of
`29
`Cutting-out.
`the
`cases
`on
`were
`shown
`immediate
`have
`the
`implant
`placed
`joint
`space
`;
`these
`were
`tion.
`The
`cut-out
`rate
`
`of
`
`from
`
`of mechanical
`implant
`(Table
`infrequent
`
`from
`II).
`
`failure
`the
`Other
`and
`
`was
`femoral
`causes
`have
`
`16.5%,
`head
`of
`been
`
`complication
`this
`with
`radiography
`postoperative
`penetrating
`into
`with
`its
`tip
`further
`considera-
`excluded
`from
`for
`the K#{252}ntscher Y-nail
`was
`8.8%
`
`five
`to
`the
`
`THE JOURNAL
`
`OF BONE
`
`AND
`
`JOINT
`
`SURGERY
`
`Fracture
`ographs,
`(TRCD)
`classification
`as
`shown
`radiographs
`fracture
`femoral
`main
`two
`anteroposterior
`tasis)
`radiographs
`compared
`with
`position
`the
`
`radi-
`pre-operative
`the
`Using
`authors
`by one
`ofthe
`was
`classified
`of Evans’
`modification
`(1980)
`of
`fracture
`six
`types
`recognises
`The
`immediate
`postoperative
`the
`to
`assess
`the
`accuracy
`of
`used
`position
`of
`the
`implant
`in the
`the
`and
`of
`displacement
`between
`the
`amount
`The
`fragments
`was
`measured
`on
`the
`fracture
`diastasis)
`and
`lateral
`(lateral
`dias-
`(AP
`(Fig.
`4)
`and
`the
`neck-shaft
`angle
`was
`of
`that
`the
`contralateral
`femur.
`The
`implant
`in
`the
`coronal
`plane
`(AP
`
`assessment.
`each
`fracture
`using
`Jensen’s
`(1949).
`This
`Figure
`3.
`were
`reduction
`head.
`
`in
`
`of
`
`ZIMMER 1042
`Page 3
`
`

`
`INTERTROCHANTERIC
`
`FEMORAL
`
`FRACTURES
`
`29
`
`Number
`patients
`
`of
`
`CUT-OUT
`GROUP
`- 3.75)
`(median
`
`CONTROL
`(median
`
`GROUP
`4.25)
`
`2
`
`3
`
`4
`Singh grade
`
`Fig.
`
`5
`
`5
`
`6
`
`distribution
`The
`patients.
`There
`
`grades
`of Singh
`is no significant
`
`in the
`difference
`
`cut-out
`between
`
`and
`
`control
`the
`groups.
`
`groups
`
`of
`
`Superior
`
`I
`
`1(cid:1)3(4)
`
`screw
`
`difference,
`This
`be
`explained
`fractures
`
`(Table
`
`by
`
`12.6%.
`it was
`hip
`sliding
`forthe
`and
`may
`possibly
`is not
`significant,
`which
`of 2-part
`(stable)
`the yneven
`distribution
`the
`fixation.
`of
`I) and by the quality
`be
`to
`appeared
`Although
`cutting-out
`General
`factors.
`old and
`80 years
`more
`common
`in women,
`patients
`under
`those
`with
`prefracture
`walking
`ability
`(Table
`Ill),
`good
`The
`these
`differences
`were
`significant.
`apparent
`not
`walking
`correlations
`with
`lower
`and
`greater
`ability
`age
`two
`subgroups
`may
`simply
`reflect
`the
`that
`these
`facts
`rate
`than
`patients
`a
`longer
`average
`survival
`of
`them
`remainder;
`and
`that
`a higher
`proportion
`able
`to stress
`their
`fracture
`fixation
`by weight-bearing.
`The mean
`cortical
`area
`ratios
`of
`the
`second metacar-
`in
`the
`cut-out
`group
`and
`control
`group
`were
`pal
`compared
`using
`unpaired
`they
`did
`not
`differ
`significantly
`(Table
`IV).
`
`of
`the
`were
`
`had
`
`the
`
`the
`t-test;
`
`V.
`Table
`for each
`
`cutting-out
`of
`Frequency
`of the
`six fracture
`subtypes
`
`Cut-out
`
`rate
`
`Fracture
`
`type
`
`Number
`
`Per cent
`
`2-part
`
`displaced
`
`Oof
`
`35
`
`0’
`
`3-part
`
`lateral
`
`3-part medial
`
`Complex
`
`Associated
`sub-trochanteric
`
`7 of49
`
`1 of24
`
`12of89
`
`2ofl9
`
`14
`
`4
`
`13
`
`11
`
`Posterior
`
`Basi-trochanteric
`
`2 of9
`
`20
`
`‘the
`2-part
`significant
`
`between
`difference
`and
`the
`fractures
`(p <0.05)
`
`rates
`the
`remainder
`
`for
`is
`
`assessments
`two
`minimal.
`In
`in
`one
`
`Anterior
`
`1/4
`(25)
`
`I
`I
`
`I
`
`1/18
`(6)
`
`6176
`
`(8)
`
`4/14
`!(29)
`
`(cid:1) 7/(cid:1)3
`I
`(30)
`
`0/1
`
`2/22
`
`(9)
`
`(22)
`
`I
`
`I
`
`Inferior
`
`Fig. 6
`
`frequency
`The
`femoral
`in the
`in parentheses.
`
`cutting-out
`of
`head,
`excluding
`
`in relation
`2-part
`
`to the
`fractures.
`
`position
`Percentages
`
`of
`
`the
`
`implant
`are
`given
`
`IV.
`Table
`of
`ratios
`difference
`
`The mean
`the
`cut-out
`between
`
`(s.d.)
`and
`the groups
`
`cortical
`and
`ages
`groups.
`control
`is not significant
`
`area
`The
`
`Age
`(years)
`
`Metacarpal
`area ratio
`
`cortical
`
`group
`
`81 .6(6.5)
`
`0.627(0.095)
`
`group
`
`83.0 (7.8)
`
`0.577(0.097)
`
`Cut-out
`(n=24)
`
`Control
`(n =40)
`
`VOL.
`
`72-B, No.
`
`1, JANUARY
`
`1990
`
`the
`of
`the
`between
`differences
`The
`cases
`27
`were
`patient
`grade
`for
`each
`Singh
`the
`cases
`30
`identical;
`were
`two
`assessments
`the
`was
`instance
`and
`in only
`a grade,
`di1(cid:1)erence
`was
`half
`patients
`Three
`of
`one whole
`grade.
`there
`a difference
`group
`control
`group
`and
`three
`from the
`from the
`cut-out
`contralateral
`sustained
`a fracture
`of
`the
`had
`previously
`remaining
`Singh
`The
`grades
`in the
`proximal
`femur.
`3.75)
`group
`cut-out
`(median
`patients
`of
`the
`=
`remaining
`than
`those
`less
`for
`generally
`slightly
`4.25);
`group
`control
`(median
`patients
`of
`the
`=
`close
`to significance
`(0. 1 < p < 0.05,
`difference
`was
`tailed
`Mann-Whitney
`U test)
`(Fig.
`5).
`There
`were
`no
`instances
`Fracturefactors.
`(Table
`fractures
`in
`2-part
`these
`35
`V);
`were
`excluded
`from further
`analysis.
`The
`cut-out
`rate was
`significantly
`in those
`fractures
`which
`had
`been
`
`the
`
`21
`were
`37
`this
`two-
`
`of cutting-out
`stable
`fractures
`
`higher
`with
`
`(p < 0.01)
`more
`than
`
`fixed
`
`ZIMMER 1042
`Page 4
`
`(cid:1)
`(cid:1)
`(cid:1)
`

`
`30
`
`T. R. C. DAVIS,
`
`J. L. SHER,
`
`A. HORSMAN,
`
`M. SIMPSON,
`
`B. B. PORTER,
`
`R. G. CHECKETTS
`
`(Table
`normal
`
`Lateral
`
`and
`not
`
`diastasis
`VI).
`diastasis
`of AP
`5 mm
`angle
`were
`neck-shaft
`the
`of
`restoration
`(Table
`VI).
`of cutting-out
`determinants
`significant
`(Fig.
`femoral
`head
`posteriorly
`in the
`placed
`Implants
`(13
`cut-out
`rate
`higher
`(p < 0.001)
`6) had
`a significantly
`in the
`coronal
`those
`placed
`centrally
`of 46
`28%)
`than
`=
`the K#{252}ntscher
`7%).
`This
`was
`so for
`both
`plane
`(9 of
`121
`=
`Y-nail
`(p < 0.05)
`and
`the
`sliding
`hip
`screw
`(p < 0.01).
`implants
`were
`centrally
`positioned
`on
`Provided
`that
`the
`cut-out
`rate
`was
`not
`signifi-
`the
`the
`lateral
`radiograph,
`a
`superior
`or
`an
`inferior
`either
`cantly
`affected
`by
`view.
`the AP
`placement
`as
`on
`seen
`For
`the
`K#{252}ntscher Y-nail
`significantly
`higher
`(p < 0.01)
`rate
`the
`perceived
`distance
`between
`the
`femoral
`articular
`surface
`was
`less
`VII).
`the
`sliding
`screw
`For
`appear
`to be
`critical.
`
`there
`alone,
`of
`cutting-out
`implant
`tip
`than
`10 mm
`this
`distance
`
`a
`
`was
`when
`and
`the
`(Table
`did
`not
`
`hip
`
`VI.
`Table
`to
`quality
`fractures
`
`Frequency
`of
`reduction,
`
`of
`
`cutting-out
`excluding
`
`related
`2-part
`
`Reduction
`
`Varus>lO#{176}
`
`Valgus>l0#{176}
`
`Varus
`
`and valgus
`
`Cutting-out
`
`Number
`
`3ofl9
`
`5of28
`
`8 of47
`
`Anatomical
`
`16 of 143
`
`Displacement
`<5mm
`>5mm
`
`Displacement
`<5mm
`>5mm
`
`on AP
`
`radiograph
`8of108
`l6of82
`
`on lateral
`
`radiograph
`lOof78
`l4ofll2
`
`‘difference
`
`significant
`
`at p<O.Ol
`
`Per
`
`cent
`
`16
`
`18
`
`17
`
`11
`
`7’
`20’
`
`13
`13
`
`VII.
`
`Table
`excluding
`
`Cutting-out
`2-part
`fractures
`
`related
`
`to
`
`the
`
`distance
`
`between
`
`implant
`
`tip
`
`and
`
`joint
`
`surface
`
`KuUtSChe
`
`r Y-nall
`
`Sliding
`
`hi
`
`p screw
`
`Total
`
`Per
`
`cent
`
`Number
`
`Per
`
`cent
`
`Implant-cortex
`distance
`(mm)
`
`Number
`
`Per
`
`cent
`
`Oto4
`
`5to9
`
`4ofl3
`
`4of21
`
`lOtol4
`
`.
`
`lof30
`
`1 of28
`
`21
`
`19
`
`3’
`
`4
`
`Number
`
`lofl3
`
`4of34
`
`7of34
`
`2 of 17
`
`8
`
`12
`
`21
`
`12
`
`5of26
`
`8of55
`
`8of64
`
`3 of45
`
`19
`
`15
`
`13
`
`7
`
`a
`is
`placed
`
`significant
`over
`
`difference
`10 mm and
`
`frequency
`the
`in
`(js<0.0l)
`under
`10 mm from thejoint
`
`of
`surface
`
`cutting-out
`
`of K#{252}ntscher
`
`> 15
`
`‘there
`Y-nails
`
`DISCUSSION
`
`position
`the
`that
`is
`finding
`important
`Our most
`determinant
`significant
`device
`is a highly
`fixation
`out.
`will
`cut
`that
`the
`implant
`probability
`central
`recommended
`(1972)
`Mulholland
`and Gunn
`radi-
`lateral
`AP
`and
`both
`on
`placement
`(as
`visualised
`posterocen-
`reported
`that
`(1979)
`ographs)
`and Kyle
`et al
`rate
`a
`low
`failure
`in
`tral
`placement
`also
`resulted
`(5%).
`hip
`screw
`the
`sliding
`placed
`Laskin
`et
`al
`(1979)
`always
`no cases
`reported
`and
`head
`posteriorly
`in the
`femoral
`236
`intertrochanteric
`of
`cutting-out
`in
`their
`series
`the
`finding
`that
`both
`our
`fractures.
`This
`contrasts
`with
`sliding
`screw
`and
`the K#{252}ntscher Y-nail
`had
`a higher
`hip
`rate
`ofcutting-out
`when
`placed
`posteriorly
`in the
`femoral
`head.
`The
`reason
`for
`this
`difference
`is not
`apparent
`and
`cannot
`be
`explained
`by
`differences
`in
`postoperative
`mobilisation.
`Regarding
`et
`al
`Jensen
`the
`articular
`We
`found
`sliding
`hip
`
`tip
`the
`of
`position
`the
`placement
`advise
`(1978)
`over
`(1979)
`Kyle
`et
`al
`and
`surface
`not
`distance
`was
`that
`this
`screw.
`However,
`implants
`
`five
`
`of
`of
`
`the
`the
`
`of
`
`space.
`
`into
`penetrating
`tips
`their
`with
`placed
`from
`to result
`thought
`was
`error
`this
`images,
`it would
`peroperative
`the
`implant
`too
`close
`the
`aim to
`place
`As
`the
`K#{252}ntscher Y-nail
`cannot
`surprising
`that
`there
`was
`a higher
`out when
`its
`tip was
`placed
`within
`surface.
`
`joint
`the
`misinterpretation
`seem
`sensible
`to
`subchondral
`telescope,
`of
`incidence
`10 mm of
`
`As
`of
`to
`
`it
`
`not
`bone.
`is
`not
`cutting-
`the
`joint
`
`of
`
`bone
`grade)
`rate.
`and
`use
`
`of
`
`rare
`
`(metacarpal
`density
`measures
`Simple
`be demonstrated
`not
`could
`and
`Singh
`area
`ratio
`cal
`contrasts
`with
`This
`the
`cut-out
`influence
`to
`1974),
`but
`Moore
`others
`(Laros
`of
`findings
`implants,
`of older
`may
`be due
`to their
`difference
`At
`unsound.
`to
`be
`biomechanically
`recognised
`ofbone
`indices
`are
`the
`only measures
`these
`simple
`easily
`be
`performed
`pre-operatively
`which
`can
`hospital.
`district
`general
`studies
`previous
`those
`with
`agree
`findings
`Our
`fractures
`in stable
`was
`cutting-out
`showed
`that
`which
`that
`1980)
`and
`T#{248}ndevold and
`Sonne-Holm
`(Jensen,
`fracture
`of
`quality
`the
`rate
`was
`determined
`by
`the
`cut
`out
`T#{248}ndevold 1980).
`(Jensen,
`Sonne-Holm
`and
`reduction
`We have
`shown
`that
`the mechanical
`failure
`rate
`
`corti-
`
`the
`the
`now
`present
`density
`in
`
`a
`
`the
`
`of
`
`THE JOURNAL
`
`OF BONE
`
`AND
`
`JOINT
`
`SURGERY
`
`the
`10 mm
`within
`critical
`were
`
`of
`
`device,
`from
`10 mm.
`for
`the
`accidently
`
`ZIMMER 1042
`Page 5
`
`

`
`INTERTROCHANTERIC
`
`FEMORAL
`
`FRACTURES
`
`31
`
`fixation
`the
`minimised
`possible
`femoral
`more
`the
`
`on
`bone
`
`intertrochanteric
`of
`reducing
`by
`placing
`by
`and
`of
`The
`success
`head.
`technical
`expertise
`the
`quality
`of
`patient.
`
`the
`the
`
`femoral
`fracture
`implant
`fixation
`of
`
`fractures
`as
`accurately
`centrally
`within
`is dependent
`the
`surgeon
`
`can
`
`be
`as
`the
`much
`than
`on
`
`the
`
`We thank Messrs
`and H.
`A. T. Cross
`J. M. Buchanan,
`J. M. Birnie,
`A.
`out
`the
`and
`filling
`us
`to
`study
`their
`patients
`P. Epstein
`for
`allowing
`Regional
`Northern
`patient
`data
`sheets. We also thank Mr A. MacNay,
`Health
`Authority
`statistician
`and Mrs
`J. Livingstone
`and Mrs
`A.
`Robson
`for
`the
`clerical
`and
`secretarial
`work
`and
`Professor
`J. Stevens
`for
`his
`interest
`and
`encouragement.
`study
`was
`generously
`funded
`by the Northern
`Regional
`Health
`Dr A. Horsman
`and Mrs
`are
`M.
`Simpson
`supported
`by
`Research
`Council
`under
`external
`scientific
`staffsupport
`No
`benefits
`in
`any
`form
`from a commercial
`party
`related
`this
`article.
`
`This
`Authority.
`the Medical
`grants.
`been
`have
`directly
`
`received
`or
`indirectly
`
`be
`or will
`to the
`
`received
`subject
`
`of
`
`Evans EM. The
`JointSurg[Br]
`
`treatment
`1949;
`
`of trochanteric
`31-B:l90-203.
`
`fractures
`
`of
`
`the femur.
`
`J Bone
`
`Jensen
`
`Jensen
`
`A, Kirby
`Horsman
`CalcjfTissueRes
`JS. Classification
`1980; 51 :803-10.
`JS, Tendevold
`treated
`with
`the
`unstable
`trochanteric
`49 :392-7.
`
`PA. Geometric
`properties
`1972; 10:289-301.
`of trochanteric
`
`of
`
`the
`
`second
`
`metacarpal.
`
`fractures.
`
`Acta Orthop
`
`Scand
`
`E, Moaning
`sliding-plate
`fractures
`
`N. Unstable
`trochanteric
`system
`: a biomechanical
`Acta
`Orthop
`III.
`
`fractures
`of
`study
`1978;
`
`Scand
`
`E. Unstable
`JensenJS,Sonne-HoImS,Tendevold
`four methods
`of
`a comparative
`analysis
`1980;
`51 :949-62.
`Orthop
`Scand
`
`trochanteric
`internal
`
`of
`
`fractures:
`fixation.Acta
`
`Jensen
`
`JS, Tendevold
`a comparative
`Orthop
`Scand
`
`E, SOIIne-HOIme
`analysis
`of
`four
`1980; 51:811-816.
`
`S. Stable
`methods
`
`of
`
`trochanteric
`internal
`
`fractures:
`Acta
`fixation.
`
`twenty-
`and
`prospective
`
`intertrochanteric
`
`of six hundred
`RF. Analysis
`Premer
`RB,
`Kyle RF,
`Gustilo
`hip fractures
`: a retrospective
`and
`intertrochanteric
`two
`J Bone Joint Surg [Am]
`study.
`1979;
`61-A
`:216-21.
`GS, Moore
`Complications
`JF.
`1974;
`Clin Orthop
`fractures.
`RS, Gruber
`AJ.
`Zimmerman
`MA,
`: a retrospective
`elderly
`hip
`in the
`the
`Orthop
`1979; 141 :188-95.
`RC, Gunn
`fractures.
`
`in
`
`fractures
`cases.
`
`of
`C/in
`
`of
`
`236
`
`Laros
`
`Laskin
`
`fixation
`
`of
`101 :110-9.
`Intertrochanteric
`analysis
`
`Muiholland
`femoral
`
`DR.
`Sliding
`J Trauma
`
`screw
`1972;
`
`fixation
`12:581-91.
`
`of
`
`intertrochanteric
`
`:218.
`
`use
`
`of
`and
`
`the KOntscher-Y
`subtrochanteric
`
`nail
`fractures
`
`in
`of
`
`the
`the
`
`A, Williams
`Sarmiento
`treatment
`with
`Joint
`Surg
`[Am]
`
`EM.
`a valgus
`1970;
`
`unstable
`The
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`52-A
`:1309-18.
`
`intertrochanteric
`I-beam
`nail-plate.
`
`and
`
`fracture:
`J Bone
`
`ofthe
`
`2nd
`
`hip.
`ed.
`
`Ci,
`In : Rockwood
`Vol.
`2. Philadelphia,
`
`Jr.
`
`fractures
`
`of
`
`the
`
`AR, Maim
`Singh M, Nagrath
`Changes
`PS.
`end
`an index
`as
`the
`femur
`of
`upper
`1970;
`52-A :457-67.
`Surg
`[Am]
`JP. Treatment
`GL, Bryant MH, O’Neill
`Wolfgang
`ofthe
`femur
`using
`sliding
`screw
`plate
`fracture
`1982; 163:148-58.
`
`of
`
`in trabecular
`osteoporosis.
`
`pattern
`J Bone
`
`the
`of
`Joint
`
`intertrochanteric
`of
`fixation.
`C/in Orthop
`
`REFERENCES
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`
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`hip
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`
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`Jewett
`fractures?
`: a randomised
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`JC. Fractures
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`1984:1211-356.
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`intertrochanteric
`JH, Hughston
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`DeLee
`
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`hip.
`
`VOL.
`
`72-B, No.
`
`1, JANUARY
`
`1990
`
`ZIMMER 1042
`Page 6