What are the recommendations for using proximal femoral lock plates (PFLP) in unstable intertrochanteric and pertrochanteric fractures?

Proximal Femoral Lock Plates: Not Recommended for Unstable Intertrochanteric/Pertrochanteric Fractures

Proximal femoral locking plates (PFLP) should NOT be used as a primary treatment option for unstable intertrochanteric and pertrochanteric fractures—cephalomedullary nails are the definitive standard of care for these fracture patterns. 1

Guideline-Based Device Selection

The American Academy of Orthopaedic Surgeons provides clear algorithmic guidance for device selection in proximal femur fractures:

For Stable Intertrochanteric Fractures:

• Use either a sliding hip screw (DHS) or cephalomedullary nail 1
• Both options are acceptable with equivalent outcomes 1

For Unstable Intertrochanteric Fractures:

• Cephalomedullary nail is mandatory 1
• Unstable patterns include: comminuted fractures, reverse obliquity patterns, subtrochanteric extension, and fractures with posteromedial comminution 1
• Lesser trochanter involvement specifically requires intramedullary fixation rather than any plating device 1

For Subtrochanteric or Reverse Oblique Fractures:

• Cephalomedullary device is the only recommended option 1, 2

Why PFLP Fails: The Evidence

The research evidence consistently demonstrates unacceptably high failure rates with proximal femoral locking plates:

Complication Rates:

• 41.4% failure rate in one series of 29 patients, with 83% of failures occurring in elderly women 3
• 31.3% implant-associated complications at medium-term follow-up, with 25% requiring revision surgery 4
• 27% overall complication rate, with major complications requiring revision in 12% of cases 5
• 45% complication rate in another series, including non-union, infection, and deformity 6

Specific Failure Mechanisms:

• Proximal screw bending, backing-out, fracture, or cut-out 3
• Plate fracture 3
• Non-union 6, 4
• Malrotation and post-traumatic hip impingement 4
• Late implant-associated infection 4

High-Risk Populations:

• Elderly women are at particularly high risk for failure (83% of complications) 3
• Active tobacco users have significantly higher complication rates (P = 0.020) 5
• Fractures with associated intracapsular femoral neck components have higher failure rates (P = 0.006) 5

When PFLP Might Be Considered (Rarely)

PFLP should only be considered in highly selected cases when absolutely no other implant is deemed appropriate based on extreme comminution and fracture complexity 5. Even in these rare scenarios:

• Patients must be explicitly informed about the high probability of revision surgery 5
• The device represents a "salvage" option when all other implants fail 6
• It is not recommended as a definitive implant 6

Common Technical Pitfalls to Avoid (If Used):

• Leaving the plate proud proximally 3
• Malposition of proximal screws within the femoral neck/head 3
• Inappropriate use of the hook plate variant 3
• Creating too rigid a construct when used as a bridging plate 3

Clinical Algorithm

For any unstable intertrochanteric or pertrochanteric fracture:

1. First-line treatment: Cephalomedullary nail 1
2. Surgical timing: Within 24-48 hours of admission 1, 7
3. Avoid: Proximal femoral locking plates as primary treatment
4. Reserve PFLP only for: Extreme cases where anatomic constraints absolutely preclude intramedullary nailing AND patient accepts high revision risk 5

The guideline evidence is unequivocal: unstable intertrochanteric fractures require cephalomedullary nails, and the research evidence demonstrates that PFLP carries unacceptably high failure rates (27-45%) compared to standard intramedullary fixation 1, 5, 6, 4, 3.