Is proximal femoral plating or proximal femoral nailing optimal for unstable intertrochanteric and/or pertrochanteric fractures involving the lesser trochanter?

Proximal Femoral Nailing is Superior to Plating for Unstable Intertrochanteric/Pertrochanteric Fractures Involving the Lesser Trochanter

For unstable intertrochanteric and pertrochanteric fractures involving the lesser trochanter, proximal femoral nailing (cephalomedullary nail) is the optimal treatment and is mandatory—plating should not be used. 1, 2

Definitive Device Selection Based on Fracture Pattern

Unstable Fractures Require Intramedullary Nailing

• A cephalomedullary nail is strongly recommended and mandatory for all unstable intertrochanteric fractures, including those with lesser trochanter involvement 1, 2
• Lesser trochanter fracture or avulsion is specifically identified as an indication requiring surgical stabilization with intramedullary fixation rather than plating 3
• Unstable patterns that mandate cephalomedullary nailing include: comminuted fractures, reverse obliquity patterns, subtrochanteric extension, fractures with posteromedial comminution, and lesser trochanter involvement 1

Why Plating Fails in This Context

• Dynamic hip screw (DHS) plating should only be used for stable intertrochanteric fractures—it is contraindicated for unstable patterns 1, 2
• The American Academy of Orthopaedic Surgeons explicitly states that sliding hip screws are not effective for unstable fractures, particularly when bone healing is compromised 1, 2
• Failure rates exceed 50% when DHS fixation is used for unstable intertrochanteric fractures with osteoporosis 1
• Lesser trochanter involvement specifically indicates an unstable fracture pattern that will not be adequately stabilized by lateral plating alone 3

Clinical Evidence Supporting Intramedullary Nailing

Functional Outcomes

• Proximal femoral nails demonstrate significantly better early walking ability at 6 weeks compared to plating devices (odds ratio 2.2, p=0.04) 4
• Short proximal femoral nails achieve 90% good or excellent outcomes at one year, with 50% of patients returning to pre-injury functional level 5
• Intramedullary nailing provides superior outcomes in terms of operating time, surgical exposure, blood loss, and complications, especially for patients with relatively small femora 5

Surgical Advantages

• Proximal femoral nails are associated with shorter operating times, less blood loss during surgery, and fewer early complications 6
• The mechanical strength of the nail and less invasive procedure make it preferable for unstable patterns 6
• Low perioperative and postoperative morbidity is consistently demonstrated with proximal femoral nails 6

Comparative Data on Plating Augmentation

• Even when DHS is augmented with a trochanter-stabilizing plate (TSP), patients experience significantly more residual pain (VAS score 28.4 vs 23.2 for A2 fractures, p<0.05) and greater implant irritation compared to intramedullary nailing 7
• While DHS+TSP may show shorter operation times, the clinical disadvantages of increased pain and implant irritation make it less favorable 7
• Reoperation rates are significantly higher with plating devices (9% vs 1%, p<0.02) compared to intramedullary nails 4

Critical Technical Considerations

Specific Contraindications to Plating

• Never use sliding hip screws or cannulated screws for pathologic fractures, as these devices are ineffective due to lack of bone healing, particularly with planned subsequent radiation 2
• DHS is not effective for pathologic fractures and alternative fixation methods or prosthetic replacement should be considered 1
• Involvement of the proximal femur associated with a fracture of the lesser trochanter is a specific indication for prophylactic surgical intervention with intramedullary fixation 3

Surgical Timing and Approach

• Surgery should be performed within 24 to 48 hours of admission for improved outcomes 1, 2
• Preoperative traction should not be used, as it has no benefit 1, 2
• Either spinal or general anesthesia is appropriate with no preference 1, 2

Common Pitfalls to Avoid

• Inadequate fracture classification leading to inappropriate implant selection—always identify lesser trochanter involvement as a marker of instability requiring intramedullary fixation 1
• Attempting to use DHS for unstable patterns will result in high failure rates and need for revision surgery 1, 4
• Technical errors such as insufficient reduction or incorrectly inserted implants significantly increase complication rates regardless of implant type 8
• Failure to restore continuity in the medial cortex of the femoral neck (Adams' arch) is a requirement that must be observed 8