Vol 2 | Issue 1 | January-April 2025 | page: 22-27 | Sachin Kale, Ashok Shyam, Sushant Srivastava, Dushyant Vashist, Akhil Gailot, Nikhil Hiwrale

Authors: Sachin Kale [1], Ashok Shyam [2], Sushant Srivastava [3], Dushyant Vashist [4], Akhil Gailot [5], Nikhil Hiwrale [5]

[1] Department of Orthopaedics, D.Y Patil School of Medicine and Hospital, Navi Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India,
[3] Department of Orthopaedics, Mata Gujri Memorial Medical College and Lions Seva Kendra Hospital, Kishanganj, Bihar, India.
[5] Junior Resident, Dr.D. Y. Patil Medical College, Nerul , Navi Mumbai

Address of Correspondence
Dr. Sachin Kale,
Department of Orthopaedics, D.Y Patil School of Medicine and Hospital, Navi Mumbai, Maharashtra, India.
Email: sachinkale@gmail.com

Abstract

Intertrochanteric fractures in the elderly are frequently treated surgically. The integrity of the lateral wall has emerged as a critical factor influencing fracture stability and post-operative outcomes. This review synthesizes findings from retrospective and controlled studies examining the impact of lateral wall fractures on surgical treatment using various fixation methods, predominantly the proximal femoral nail antirotation (PFNA) and dynamic hip screw. The evidence suggests that while lateral wall fractures can increase operative time and blood loss with PFNA, they do not necessarily lead to inferior functional outcomes or higher complication rates when compared to cases without lateral wall involvement, provided good reduction and proper implant positioning are achieved. However, in extramedullary fixation, a compromised lateral wall is associated with higher reoperation rates, necessitating consideration of lateral wall reconstruction techniques or alternative implants. This review highlights the importance of comprehensive pre-operative assessment, meticulous surgical technique, and appropriate implant selection in managing these complex fractures.
Keywords: lateral wall , PFN , DHS, Intertrochanteric femur fracture, Complex

Introduction

The lateral wall of the femur in the context of intertrochanteric fractures is a crucial structural element whose integrity significantly impacts the stability of the fracture and the success of surgical fixation. (1,2)
● Defining the lateral wall: Gotfried initially highlighted its importance in unstable fractures. Palm et al. defined its proximal extent as the vastus lateralis ridge. More recently, Gao et al. provided a comprehensive three-dimensional computed tomography (CT)-based definition: the superior border is the vastus lateralis ridge, and the inferior border is the intersection of the lateral femoral cortex and a tangent to the inferior femoral neck. This definition is considered more encompassing for surgical planning as it includes reverse oblique fractures (3,4,5).
● Measuring lateral wall thickness: Hsu et al. defined lateral wall thickness as the distance on an anteroposterior radiograph from a point 3 cm below the vastus lateralis ridge, angled 135° upward to the fracture line. They identified a threshold of 20.5 mm, below which the lateral wall was considered incompetent and at higher risk of post-operative fracture. This definition has been incorporated into the 2018 AO/OTA classification. However, Sun et al. argued that the precise thickness should be measured by CT (typically 2–4 mm for the lateral cortex alone), as Hsu’’s definition includes more than just the cortical thickness.
● Clinical significance: A compromised lateral wall can biomechanically convert an intertrochanteric fracture into a subtrochanteric fracture, leading to medial displacement of the distal fragment, varus angulation, limb shortening, and abductor mechanism insufficiency. An intact lateral wall provides lateral buttress for the proximal fragment and contributes to rotational and varus stability, especially with extramedullary fixation. Its fracture has been associated with increased reoperation rates following dynamic hip screw (DHS) fixation (6). Even with intramedullary fixation, a fractured lateral wall might reduce the implant’s resistance to varus forces.

Methods
This narrative review was conducted by synthesizzing information from the provided source articles and our previous conversation. The sources include a retrospective cohort study, a controlled study, and a review article that specifically address the topic of intertrochanteric fractures with lateral wall involvement. The evidence presented encompasses data on patient demographics, surgical techniques (primarily Proximal Femoral Nail Antirotation [PFNA] and DHS), operative characteristics (time and blood loss), functional outcomes (Harris Hip Score [HHS], Parker − Palmer mobility score [PPMS], fracture healing time, and complication rates in elderly patients with intertrochanteric fractures, with a specific focus on the presence or absence of lateral wall fractures. The definitions and classifications of lateral wall fractures, as discussed in the literature, were also considered. ( Fig . 1, 2)

Intramedullary fixation (PFNA) in detail
The PFNA is a commonly used intramedullary device for treating intertrochanteric fractures in the elderly. The studies by Tang et al. and Deng et al. offer detailed insights into its performance in the presence of lateral wall fractures (7).

● Operative characteristics:
o Tang et al. reported a statistically significant increase in operative time (approximately 3 min longer) and intraoperative blood loss (approximately 77 mL more) in the incomplete lateral wall fracture group compared to the intact group (P < 0.01).
o Deng et al. also found a significantly longer operative time (approximately 7 min longer) in the incompetent lateral wall group (P = 0.046).
o These findings suggest that achieving adequate reduction in the presence of a lateral wall fracture can be more challenging and time-consuming, potentially requiring more fluoroscopic imaging and manipulation.

● Functional outcomes: Both studies consistently found no statistically significant difference in functional outcomes measured by the HHS at various follow-up points. Tang et al. reported comparable HHS at 3, 6, 12, and 24 months post-operatively (P > 0.05). Deng et al. also found no significant difference in mean HHS at the final follow-up (P = 0.123). Similarly, Tang et al. found no significant difference in the PPMS between the groups.

● Complication rates and healing:
o Tang et al. found no significant difference in the time to weight-bearing, time of fracture healing, or the incidence of complications such as post-operative fixation failure, loss of reduction, cutout, implant breakage, malunion, non-union, deep vein thrombosis, and wound infection between the groups.
o Deng et al. also reported no significant differences in weight-bearing time, clinical healing time, or complications like deep vein thrombosis, superficial infection, revision, and mortality.
o These findings indicate that despite the potential for increased surgical difficulty, PFNA can provide stable fixation and facilitate comparable healing and functional recovery regardless of lateral wall integrity, provided a good reduction is achieved.

● Conclusion on PFNA: The conclusions from both Tang et al. and Deng et al. support the notion that intramedullary nailing with PFNA is a sufficient treatment for intertrochanteric fractures with or without a lateral wall fracture. They suggest that the key to successful outcomes lies in achieving good fracture reduction and proper implant positioning, which may be more challenging but ultimately achievable in cases with lateral wall fractures.

Extramedullary fixation (DHS) and lateral wall fractures in detail
The DHS has historically been considered the “gold standard” for stable intertrochanteric fractures. However, its limitations in the presence of lateral wall fractures are well-documented(8).

● Increased reoperation risk: Palm et al.’s study highlighted a significantly higher reoperation rate in patients with lateral wall fractures treated with DHS (22% vs. 3%). This underscores the critical role of an intact lateral wall for the stability of DHS fixation. When the lateral wall is fractured, the proximal fragment lacks lateral support, increasing the risk of collapse, screw cutout, and subsequent failure.

● Lateral wall thickness as a predictor: Hsu et al. identified a lateral wall thickness of <20.5 mm as a significant predictor of post-operative lateral wall fracture in patients treated with DHS. This suggests that in cases with a thin or fractured lateral wall, DHS may not provide adequate stability. Pradeep et al. also found that an intraoperative lateral wall thickness of <21 mm was associated with a higher risk of intraoperative lateral wall fracture during DHS fixation.

● Need for lateral wall reconstruction: Given the instability associated with lateral wall fractures and DHS, reconstruction of the lateral wall is often advocated. Techniques include using a trochanter stabilising plate (TSP), which acts as a lateral buttress, or cerclage wires and lag screws. Hsu et al. reported improved outcomes with TSP in A2 type fractures with thin lateral walls treated with DHS. Wu et al.’s review also discusses TSP as a method to prevent lateral wall displacement. ( Fig 3,4)

● Limitations of DHS in unstable fractures: Multiple studies cited in Wu et al.’s review suggest that DHS is prone to failure in unstable intertrochanteric fractures or those with severe osteoporosis. The sliding mechanism and single lag screw may not provide sufficient rotational stability in the absence of a competent lateral wall.

Alternative fixation methods and lateral wall considerations
The sources also touch upon alternative fixation methods and their relevance to lateral wall integrity:

● Anatomic locking plates: Hu et al. suggested that anatomic locking plates could be beneficial for intertrochanteric fractures with lateral wall cracks, especially in comminuted fractures where intramedullary nailing might risk further lateral wall injury. These plates can potentially capture multiple lateral wall fragments, providing better stability (9).

● Percutaneous compression plate (PCCP): Wu et al. mention PCCP as having a smaller head screw diameter, potentially reducing the risk of lateral wall damage compared to DHS. However, they also note that PCCP requires a higher level of technical expertise (10).

● Proximal femoral locking plate (PFLP): Johnson et al. (cited in the previous response, though the excerpt wasn’t provided this time) found this to be an option, but its performance in the context of lateral wall fractures specifically isn’t detailed in these sources. Wu et al. suggest it might be useful when the greater trochanter is comminuted.

● Intramedullary nail with reconstruction plate: Wang et al. (cited previously, excerpt not present) found that combining an intramedullary nail with a reconstruction plate resulted in higher HHS and PPMS in unstable fractures with lateral wall damage. This suggests that augmenting intramedullary fixation with lateral wall support can be beneficial in certain complex cases.

Results
The reviewed sources provide several key insights into the surgical treatment of intertrochanteric fractures with lateral wall involvement:

● Intramedullary fixation (PFNA):
o Operative time and blood loss: Tang et al.’s retrospective study found that patients with incomplete lateral wall fractures treated with PFNA had longer operation times (54.1 ± 8.74 min vs. 51.0 ± 9.86 min) and more intraoperative blood loss (228.4 ± 48.8 ml vs. 151.3 ± 43.5 ml) compared to those with intact lateral walls (P < 0.01). Deng et al.’s controlled study also reported a longer operative time in the incompetent lateral wall group (58.54 ± 18.14 mins vs. 51.79 ± 17.77 mins, P = 0.046).
o Functional outcomes: Both studies reported no significant difference in functional outcomes as measured by HHS between the groups with and without lateral wall fractures at various follow-up points (up to 24 months in Tang et al. and at final follow-up in Deng et al.). Tang et al. also found similar results with PPMS.
o Complication rates: Tang et al. found no difference in weight-bearing time, time of fracture healing, and complications (including postoperative fixation failure, cutout, implant breakage, and non-union) between the two groups. Deng et al. similarly found no significant difference in weight-bearing, clinical healing, or complications (deep vein thrombosis, wound infection, revision, and mortality).
o Conclusion on PFNA: Both Tang et al. and Deng et al. concluded that lateral wall thickness does not significantly affect functional results or complication rates when intertrochanteric fractures are treated with PFNA, although lateral wall fractures may be associated with increased blood loss and operative time. They suggest that intramedullary nailing alone may be sufficient.

● Extramedullary fixation (DHS):
o Gotfried highlighted the importance of an intact lateral trochanteric wall for the stabilization of unstable fractures and noted that fixation failures with DHS were often due to lateral wall fractures.
o Palm et al. found a significantly higher reoperation rate (22% vs. 3%) in intertrochanteric fractures with lateral wall fractures treated with DHS compared to those with an intact lateral wall. This suggests that a fractured lateral wall increases the risk of reoperation with DHS.
o Hsu et al. identified a lateral wall thickness threshold of 20.5 mm as significantly affecting post-operative lateral wall fracture in DHS treatment. They later reported that a TSP improved outcomes in A2 type fractures with critical thin lateral walls treated with DHS by reducing post-operative lateral wall fracture and reoperation rates.
o The review by Wu et al. discusses the limitations of DHS in unstable fractures or those with osteoporosis and highlights the use of TSP and PCCP as alternatives, while noting the potential drawbacks of each. They emphasize that for unstable fractures with lateral wall involvement, primary reconstruction of the lateral wall is crucial.

● Other fixation methods and considerations:
o Hu et al. suggested that anatomic locking plates could be used for intertrochanteric fractures with lateral wall cracks, especially for severe comminuted fractures.
o Wu et al. mention that in cases of comminuted lateral wall fractures, small condylar plates can be used for reconstruction, and proximal femoral locking plates may be a better option when the greater trochanter is comminuted or a longitudinal fracture line passes through the lateral wall.

● Lateral wall definition and significance:
o The definition of the lateral wall has evolved, with Gao et al.’s three-dimensional CT definition (superior border: Vastus lateralis ridge; inferior border: Intersection of lateral femoral cortex and inferior femoral neck tangent) being considered more comprehensive for guiding surgical choices.
o The integrity of the lateral wall is recognized as essential for preventing fixation failure and reoperation. Its fracture can lead to medial displacement of the distal fragment and altered hip biomechanics.

Conclusion
The surgical management of intertrochanteric fractures with lateral wall involvement requires a nuanced approach. Intramedullary fixation with PFNA appears to be a viable option, demonstrating comparable functional outcomes and complication rates regardless of lateral wall integrity, although longer operative times and increased blood loss may occur in the presence of a lateral wall fracture. Good fracture reduction and proper implant positioning are paramount for successful outcomes with PFNA.
In contrast, extramedullary fixation with DHS is associated with a higher risk of reoperation in the presence of a lateral wall fracture. In such cases, lateral wall reconstruction techniques, such as using a TSP or other supplementary fixation, or considering alternative implants like locking plates, may be necessary to improve stability and reduce the risk of failure.
Comprehensive pre-operative assessment, potentially including 3D CT imaging in complex cases, is crucial for understanding the fracture pattern and anticipating potential lateral wall issues. Surgeons should be proficient in various fixation techniques and be prepared to adapt their strategy based on the intraoperative findings and the specific characteristics of the lateral wall injury.

Learning Point of View
From the reviewed information, the following learning points can be highlighted for clinicians managing intertrochanteric fractures:
● Recognize the importance of the lateral wall: The integrity of the lateral wall significantly influences the stability of intertrochanteric fractures and can predict the success of surgical fixation, particularly with extramedullary devices.
● Consider PFNA as a robust option: For elderly patients with intertrochanteric fractures, PFNA demonstrates comparable outcomes with or without lateral wall fractures, suggesting it can be a reliable first-line treatment. Be aware of potential for increased operative time and blood loss in cases with lateral wall involvement.
● Exercise caution with DHS in lateral wall fractures: When using DHS, be particularly vigilant in cases with existing or iatrogenic lateral wall fractures. Consider supplementary fixation (TSP) or alternative implants if the lateral wall is compromised to minimise reoperation risk.
● Utilise preoperative imaging effectively: In complex fracture patterns or when lateral wall involvement is suspected on plain radiographs, consider 3D CT imaging for a more detailed assessment to aid in surgical planning.
● Master lateral wall reconstruction techniques: Be familiar with various techniques for lateral wall reconstruction (e.g., TSP, wires, small plates) to address instability when using extramedullary fixation in the presence of a lateral wall fracture.
● Prioritise reduction and implant positioning: Regardless of the implant choice, achieving and maintaining an anatomical or acceptable reduction and ensuring proper implant placement are critical determinants of outcome, potentially mitigating the negative effects of a lateral wall fracture, especially with intramedullary nails.
● Stay updated on classification systems: Familiarize yourself with the latest AO/OTA classification, which incorporates lateral wall integrity, as this can guide treatment decisions.
● Consider Alternative fixation for specific cases: In severely comminuted fractures or those with specific greater trochanter involvement and lateral wall compromise, anatomic locking plates might offer better stability for the lateral fragments.
By understanding the role of the lateral wall and being proficient in various surgical techniques, clinicians can optimize the treatment of intertrochanteric fractures, minimize complications, and improve functional outcomes for elderly patients.
By considering these detailed points and the supporting evidence from the sources, clinicians can develop a more comprehensive understanding of the management of intertrochanteric fractures with lateral wall involvement and make more informed treatment decisions.

References

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How to Cite this article: Kale S, Shyam A, Srivastava S, Vashist D, Gailot A, Hiwrale N. Surgical Treatment for Intertrochanteric Fractures with Lateral Wall Involvement: A Narrative Review. Journal of Orthopaedic Complications | January-April 2025;2(1):22-27.

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