What are the current guidelines for surgical fixation of pertrochanteric fractures in patients aged 60-80 years?

Surgical Fixation of Pertrochanteric Fractures in Patients Aged 60-80 Years

For unstable pertrochanteric fractures (comminuted, reverse obliquity, or subtrochanteric extension), cephalomedullary nail fixation should be used, while stable intertrochanteric fractures can be treated with either a sliding hip screw or cephalomedullary nail. 1

Fracture Classification and Implant Selection

The choice of fixation depends critically on fracture stability:

Stable Intertrochanteric Fractures

• Either a sliding hip screw OR a cephalomedullary device is recommended (strong evidence, strong recommendation) 1
• Both options provide equivalent outcomes for simple two-part fractures without significant comminution 1
• The sliding hip screw remains favored by some surgeons for straightforward stable patterns 1

Unstable Fractures (The Critical Decision Point)

• Cephalomedullary nail fixation is strongly recommended for the following patterns (strong evidence, strong recommendation): 1

  • Unstable intertrochanteric fractures with comminution
  • Subtrochanteric fractures
  • Reverse obliquity fractures
  • Fractures with posteromedial or lateral cortex compromise 2

• The rationale for intramedullary nailing in unstable patterns includes more efficient load transfer, proximity to the medial calcar, shorter lever arm closer to the mechanical axis, and better biomechanical stability 2

Nail Length Selection

• Either short or long cephalomedullary nails may be used (limited strength of evidence, limited strength option) 1
• This represents an area where evidence is insufficient to make a definitive recommendation between the two options 1

Technical Considerations to Minimize Complications

Critical Technical Points

• Proper implant placement in the femoral head is the single most important factor in preventing cutout and failure 3
• A well-executed osteosynthesis with optimal screw positioning is the best assurance of good outcomes regardless of implant choice 3
• For unstable fractures (Jensen Type 4-5, AO 31A2.2 and above), consider using a second anti-rotational screw to prevent varus collapse and cutout 4

Common Complications to Avoid

• Cutout from the femoral head remains the primary failure mode regardless of implant type 2, 3
• Technical errors account for most complications including: malalignment, wrong lag screw length, malrotation (≥20°), and periprosthetic fracture 2
• Less than ideal placement of the implant in the femoral head is typically the reason for operative failure 3

Perioperative Management Protocol

Anesthesia

• Either spinal or general anesthesia is appropriate (strong recommendation) 1

Blood Loss Management

• Tranexamic acid should be administered to reduce blood loss and transfusion requirements (strong evidence, strong recommendation) 1

Pain Management

• Multimodal analgesia incorporating a preoperative nerve block is recommended (strong evidence, strong recommendation) 1
• Specifically, iliofascial blocks are effective for pertrochanteric fractures 1

Postoperative Weight-Bearing

• Immediate full weight-bearing as tolerated is recommended after cephalomedullary nail fixation (limited strength of evidence, limited strength option) 1

VTE Prophylaxis

• VTE prophylaxis should be used in all hip fracture patients (moderate evidence, strong recommendation) 1
• Sequential compression devices during hospitalization plus pharmacologic prophylaxis (e.g., enoxaparin for 4 weeks postoperatively) 1

Blood Transfusion

• Transfuse for symptomatic anemia (moderate evidence, moderate recommendation) 1
• Maintain a transfusion threshold no higher than 8 g/dL in asymptomatic postoperative patients 1

Osteoporosis Evaluation

• All patients should undergo evaluation and treatment for osteoporosis (strong evidence, strong recommendation) 1
• Order outpatient DEXA scan and measure vitamin D, calcium, and parathyroid hormone levels during hospitalization 1
• Refer to bone health clinic or establish Fracture Liaison Service for secondary fracture prevention 1

Interdisciplinary Care

• Interdisciplinary care programs should be used to decrease complications and improve outcomes (strong recommendation) 1
• This is particularly important in the 60-80 age group where comorbidities are common but patients may still have good functional status 1

Key Pitfalls to Avoid

• Do not use preoperative traction for hip fracture patients (strong evidence, strong recommendation) 1
• Avoid delayed surgery—aim for operative intervention within 24-48 hours when medically cleared 5, 6
• Do not underestimate fracture instability—signs include posteromedial cortex compromise, lateral cortex involvement, subtrochanteric extension, or reverse obliquity pattern 2
• Ensure optimal screw placement in the center-center or inferior-central position of the femoral head to prevent cutout 3