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Eur J Trauma Emerg Surg (2014) 40:249264 DOI 10.1007/s00068-013-0366-3
REVIEW ARTICLE
Pertrochanteric fractures: tips and tricks in nail osteosynthesis
A. H. Ruecker J. M. Rueger
Received: 11 November 2013 / Accepted: 29 December 2013 / Published online: 29 January 2014 Springer-Verlag Berlin Heidelberg 2014
AbstractIntroduction Intramedullary xation of intertrochanteric fractures has become the standard method of xation especially in unstable fracture types. Even though there have been developments on implant design and technology, the surgical technique of reduction and implant positioning remains the mandatory factor in treating these fractures successfully. The advantages of nailing in the mainly elderly patients sustaining intertrochanteric femur fractures are a short lever arm and a lateral support in the trochanter supplied by the nail. The disadvantages are that it is often harder to achieve a closed reduction of a displaced fracture and to maintain the reduction with the intramedullary implant.
Tips and tricks To obtain and maintain anatomic reduction and a secure fracture xation, the surgical approach and xation technique is of great importance. It starts with correct patient positioning, fracture reduction (accounting for varus dislocation and dislocation of exed fragments), choosing the correct nail entry point and perfect lag screw positioning within the head-neck fragment and distal locking. To maintain the reduction achieved intraoperatively, the decision has to be made to use a cerclage wiring or to tolerate fracture gaps in the metaphyseal area. Intra-operative controlled compression of the neck or the subtrochanteric area is of great importance to reduce delayed unions or nonunions.
Summary Intramedullary xation of unstable per-, inter-or subtrochanteric fractures shows biomechanical advantages compared to extramedullry xation techniques. Even though there have been several amendments and developments of implants, a better implant does not compensate for an inadequate surgical approach or decient surgical techniques which are paramount for successful treatment. When xing fractures with intramedullary nailing systems, the surgeon should always try to achieve anatomic reduction and a perfect implant positioning to allow immediate full weight bearing without an increased risk of cut-out, non-union and implant failure.
Keywords Intertrochanteric Fracture Femur Fixation
Introduction
Since the 1940s intertrochanteric fractures have been treated with intramedullary nailing and this technique subsequently became state of the art treatment for femoral shaft fractures in the 1950s. In 1967, Zickel [1,...