Surgical Procedure for Intertrochanteric Femur Fracture Treatment
For unstable intertrochanteric fractures, an antegrade cephalomedullary nail is the preferred surgical treatment due to superior outcomes in terms of morbidity and mortality compared to other fixation methods. 1
Preoperative Assessment
- Evaluate fracture pattern and stability using radiographic imaging
- Assess for comorbidities that may affect surgical outcomes
- Review patient's functional status, mobility, and pain level
- Check metabolic status, skin condition, and nutritional status 1
- Differentiate between pathologic and traumatic fractures 1
- Consider bone scan or long bone survey if metastatic disease is suspected 1
Anesthesia Considerations
- Either spinal/regional or general anesthesia can be used
- Regional anesthesia may reduce postoperative confusion 1
- Consider peripheral nerve blockade as an adjunct for postoperative pain control
- Avoid opioid analgesics as the sole adjunct due to risk of respiratory depression and confusion 1
Surgical Procedure for Unstable Intertrochanteric Fracture
Step 1: Patient Positioning
- Position patient supine on a fracture table
- Apply traction to achieve fracture reduction under fluoroscopic guidance
Step 2: Surgical Approach
- Make a small incision (approximately 3-5 cm) at the greater trochanter
- Identify the entry point at the tip of the greater trochanter
Step 3: Entry Point and Reaming
- Create entry portal using an awl
- Insert guide wire into the femoral canal
- Ream the proximal femur to accommodate the nail
Step 4: Nail Insertion
- Insert the antegrade cephalomedullary nail down the femoral canal
- Confirm proper positioning with fluoroscopy
Step 5: Lag Screw Placement
- Make a small lateral incision for the lag screw
- Insert guide pin into femoral neck and head under fluoroscopic guidance
- Position the guide pin in the center or slightly inferior position in the femoral head
- Measure for appropriate lag screw length
- Ream for the lag screw
- Insert the lag screw through the nail into the femoral head
Step 6: Distal Locking
- Insert distal locking screws through the nail to prevent rotation
- Verify final construct position with fluoroscopy
Step 7: Wound Closure
- Irrigate the wound
- Close in layers
- Apply sterile dressing
Alternative Treatment Options
For stable intertrochanteric fractures, a sliding hip screw may be favored 1, though cephalomedullary nails are increasingly used for all types of intertrochanteric fractures due to their biomechanical advantages 2.
In elderly patients with poor bone quality or highly comminuted fractures, hip arthroplasty may be considered as an alternative, especially when:
- There is high risk of fixation failure
- The patient has concomitant intra-articular pathology
- Early weight-bearing is critical for the patient's recovery 3
Postoperative Management
- Initiate early mobilization to reduce complications 1
- Provide appropriate pain management
- Implement wound care protocols
- Begin weight-bearing as tolerated in most cases with cephalomedullary nails
- Monitor for complications including infection, hardware failure, and non-union
Potential Complications and Prevention
- Screw cut-out: Ensure proper lag screw placement in the femoral head
- Hardware failure: Use appropriate implant for fracture pattern
- Secondary femur fracture: Occurs in 0.5-3% of cases following cephalomedullary nailing 2
- Non-union: More common in pathologic fractures or with inadequate reduction
- Infection: Use prophylactic antibiotics and proper surgical technique
Follow-up Protocol
- Radiographic evaluation at 6 weeks, 3 months, 6 months, and 1 year
- Assess fracture healing, implant position, and potential complications
- Evaluate functional recovery and need for rehabilitation
The surgical treatment of intertrochanteric fractures requires careful attention to fracture pattern, implant selection, and surgical technique to achieve predictable union, allow early weight-bearing, and avoid fixation failure or excessive deformity 4.