A study of the role of osteotomy in unstable intertrochanteric fractures. Resorbable cement for the augmentation of internally-fixed unstable trochanteric fractures. A prospective, randomised multicentre study. Treatment of unstable intertrochanteric fractures of the femur: a prospective trial comparing anatomical reduction and valgus osteotomy. HA-coated screws decrease the incidence of fixation failure in osteoporotic trochanteric fractures. How effective are osteotomies for unstable intertrochanteric fractures? Unstable intertrochanteric fracture of the femur. A prospective randomised study comparing anatomical reduction and medial displacement osteotomy. Locking and compression of the lag screw in trochanteric fractures is not beneficial. A prospective, randomized study of 153 cases. Unstable trochanteric fractures augmented with calcium phosphate cement. A prospective randomized study using radiostereometry to measure fracture stability. Reduction of temperatures generated by the triple reamer within the femoral head. A prospective controlled trial of valgus osteotomy in the fixation of unstable pertrochanteric fractures of the femur.
Osteotomy has been used in 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 study on 138 patients, all having been fixed by dynamic hip screen, comparing anatomical reduction with medialisation osteotomy. The groups were similar in terms of age, gender and fracture configuration. There was no difference in final results in both groups except that operation time was longer in osteotomy group and the blood loss was more. 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 anatomical reduction may benefit from an osteotomy. We undertook a multicentre, prospective study of a series of 112 unstable trochanteric fractures in order to evaluate if internal fixation with a sliding screw device combined with augmentation using a calcium phosphate degradable cement (Norian SRS) could improve the clinical, functional and radiological outcome when compared with fractures treated with a sliding screw device alone. Pain, activities of daily living, health status (SF-36), the strength of the hip abductor muscles and radiological outcome were analysed. Six weeks after surgery, the patients in the augmented group had significantly lower global and functional pain scores (p < 0.003), less pain after walking 50 feet (p < 0.01), and a better return to the activities of daily living (p < 0.05). At follow-up at six weeks and six months, those in the augmented group showed a significant improvement compared with the control group in the SF-36 score. No other significant differences were found between the groups. We conclude that augmentation with calcium phosphate cement in unstable trochanteric fractures provides a modest reduction in pain and a slight improvement in the quality of life during the course of healing when compared with conventional fixation with a sliding screw device alone. A series of 100 consecutive patients with unstable intertrochanteric fractures were treated by compression hip screw fixation; 55 patients had an anatomical reduction (Group 1) and 45 patients a Sarmiento osteotomy and valgus reduction (Group 2). Group 1 spent an average of 10 days less in hospital than Group 2 (21 days compared with 31 days) (P less than 0.02). They also had a greater chance of returning to their pre-injury accommodation and of achieving their pre-injury walking capability. Radiological failure of fracture fixation, with varus angulation of the femoral head by cutting out of the screw, was seen seven times in Group 1 but only once in Group 2. Anatomical reduction provides better clinical results than valgus osteotomy in the patient with an unstable intertrochanteric fracture stabilized by a compression hip screw. The capacity for failure of fracture fixation is greater, however, in the former. Valgus osteotomy provides a simple means of securing a stable reduction of the fracture which cannot be satisfactorily reduced by closed means. This study was done to determine if elderly patients with trochanteric fractures and with osteoporosis could benefit from treatment with a dynamic hip screw fixed with HA-coated AO/ASIF screws. One hundred twenty patients with AO, A1, or A2 trochanteric fractures were selected. Patients were divided into two groups and randomized to receive a 135 degree-four-hole dynamic hip screw fixed with either standard lag and cortical AO/ASIF screws (Group A), or HA-coated lag and cortical AO/ASIF screws (Group B). Lag screw cutout occurred in four patients in Group A, but not in any patients in Group B. In Group A, the femoral neck shaft angle was 134 degrees +/- 5 degrees postoperatively and 127 degrees +/- 12 degrees at 6 months. In Group B, the femoral neck shaft angle was 134 degrees +/- 7 degrees postoperatively and 133 degrees +/- 7 degrees at 6 months. The Harris hip score at 6 months was 60 +/- 25 in Group A and 71 +/- 18 in Group B. The superior results of Group B can be attributed to the increased screw fixation provided by the HA-coated screws. We recommend lag screws coated with HA for dynamic hip screw fixation, especially in osteoporotic bone. 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. 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. 153 patients with a trochanteric hip fracture were operated on with a compression hip screw (CHS) and followed for 4 months. They were randomized into 2 groups, with or without a key and compression of the lag screw. Greater sliding of the lag screw was noted in cases where the compression screw and the key were used, especially in women over 80 years of age and in patients with a previous fracture indicating osteoporotic bone. Use of a key and compression of the lag screw gave no advantage, and we do not recommend this for treatment of trochanteric hip fractures. Internally fixed unstable trochanteric fractures might be difficult to retain in position during healing. Secondary displacement might lead to malunion and poor functional result. The aim with this study was to measure whether augmentation with resorbable calcium-phosphate cement could improve fracture stability as shown in biomechanical studies.
                26 ambulatory patients with an unstable trochanteric fracture were randomized to treatment with a sliding screw device alone (Controls) or the same device combined with calcium-phosphate cement for augmentation (Augmented). All patients were allowed unrestricted weight bearing after surgery. Fracture movement was measured with radiostereometry (RSA) at 1 and 6 weeks and at 6 months.
                Two patients died during the study period due to unrelated causes and another three were excluded due to technical problems with the RSA in two and concomitant illness in one. 21 patients (11 Augmented and 10 Controls) were followed according to the study protocol. At 1 week the augmented fractures had moved on average 1.9+/-1.7 mm while movement in the controls was 4.0+/-2.4 mm (p < 0.05). The average total movement from the day after surgery until 6 months, when all fractures had healed, was 7.8+/-6.2 mm for the augmented fractures and 13.2+/-4.3 mm for the controls (p < 0.05). Varus angulation was the most pronounced rotational movement for both groups although augmented fractures revealed less varus angulation compared with controls at all time points. Rotation around the longitudinal and transversal axes were small with no significant differences between treatment groups.
                Augmentation with calcium-phosphate cement improved the stability of unstable trochanteric fractures fixed with a sliding screw device. The improvement was most pronounced for varus angulation and lateral and distal migration of the head and neck fragment. The triple reamer is a convenient tool for reaming the proximal femur when using a sliding screw and plate device, but unnecessarily high temperatures may be generated within the femoral head while the lateral cortex is being reamed. Nineteen female patients over 60 years old were randomized to either the standard or a modified reaming technique with the triple reamer during internal fixation of proximal femoral fractures. Temperatures generated within the femoral head were measured. Results showed a mean peak temperature of 51.9 degrees C (range 42-66) using the standard method and 46.3 degrees C (range 40-52) using the modified method (P = 0.07). A significant difference (P < 0.05) was found in the duration of temperature elevation above the critical 44 degrees C (17.4s vs 5.7s), it being prolonged in the standard group. Even in this osteoporotic patient group, damaging temperatures which may contribute to the mechanical failure of fixation, are generated within the femoral head. A simple method to avoid this problem is described. A total of 62 patients with unstable pertrochanteric fractures of the neck of the femur was subjected to either nail plating with 130 degrees neck-shaft angle or valgus osteotomy using a neck-shaft angle of at least 140 degrees. The patients were assessed in terms of ability to walk and stability of fracture fixation. A clear superiority of valgus osteotomy over the controls was demonstrated in terms of fracture fixation, but the difference in terms of ability to walk was less remarkable.
There is inadequate evidence to support the use of osteotomy for internal fixation of a trochanteric hip fracture. Similarly, there is insufficient evidence to support the use of the other techniques examined in the trials included in this review.