What is the preferred treatment for an elderly patient with an intertrochanteric fracture, osteosynthesis or hip replacement?

Intertrochanteric Fracture Management in Elderly Patients

For elderly patients with intertrochanteric fractures, osteosynthesis (internal fixation) is the definitive treatment, not hip replacement. 1, 2

Treatment Algorithm Based on Fracture Stability

Stable Intertrochanteric Fractures

• Use either a sliding hip screw OR a cephalomedullary nail—both are equally recommended. 1
• The sliding hip screw remains the preferred first-line option for simple two-part fractures with intact lateral and posteromedial cortices. 2
• Both devices allow immediate full weight-bearing as tolerated postoperatively. 2

Unstable Intertrochanteric Fractures

• A cephalomedullary nail is mandatory for: 1, 2
  • Comminuted fracture patterns
  • Loss of posteromedial cortical support
  • Lateral wall compromise
  • Reverse obliquity fractures
  • Subtrochanteric extension

Why Osteosynthesis Over Hip Replacement

The evidence strongly favors internal fixation over arthroplasty for intertrochanteric fractures:

• Hip replacement is NOT indicated for intertrochanteric fractures—it is reserved for femoral neck fractures, which are a completely different injury pattern. 1
• Osteosynthesis preserves the native hip joint and avoids long-term prosthetic complications. 3
• When comparing internal fixation to hemiarthroplasty in elderly patients with intertrochanteric fractures, internal fixation shows better survival rates and lower mortality (34.2% vs 48.8% mortality). 3
• Hip replacement after failed osteosynthesis is a salvage procedure, not a primary treatment option. 4

Critical Technical Considerations

Implant Positioning

• Optimal lag screw placement in the femoral head is critical—poor positioning is the primary cause of cut-out failure regardless of implant type. 5
• Target tip-apex distance should be ≤25mm to minimize cut-out risk. 6
• Maintain femoral neck-shaft angle between 120-140 degrees. 6

Special Technique for Unstable Patterns

• In elderly patients with poor bone quality and unstable fractures, cement augmentation of the dynamic hip screw significantly reduces complications. 7
• PMMA cement augmentation (10-19 mL) reduces screw sliding, femoral shortening, and varus collapse compared to conventional DHS alone (p < 0.001 for all parameters). 7
• The overall complication rate is significantly lower with cemented DHS in unstable patterns. 7

Perioperative Management Essentials

All elderly hip fracture patients require: 1

• Multimodal analgesia with preoperative nerve block (strong recommendation)
• Tranexamic acid administration to reduce blood loss and transfusion requirements
• Interdisciplinary care programs to decrease complications
• Either spinal or general anesthesia (both equally appropriate)

Common Pitfalls to Avoid

• Do not confuse intertrochanteric fractures with femoral neck fractures—the latter may require arthroplasty, but intertrochanteric fractures are treated with fixation. 1
• Do not use a sliding hip screw for reverse obliquity or subtrochanteric patterns—these mandate cephalomedullary nailing. 1, 2
• Do not underestimate lateral wall integrity—compromise mandates intramedullary fixation over sliding hip screw. 2
• Inadequate implant positioning causes most failures, not implant selection. 5

Postoperative Protocol

• Allow immediate full weight-bearing as tolerated after cephalomedullary nail fixation. 2
• Early mobilization with physical training and muscle strengthening. 1
• Systematic osteoporosis evaluation including DXA scanning, calcium/vitamin D supplementation, and consideration of pharmacological treatment to prevent subsequent fractures. 1