What is the role of proximal femoral lock plates (PFLP) in treating pertrochanteric fractures?

Proximal Femoral Lock Plates for Pertrochanteric Fractures

Proximal femoral locking compression plates (PFLCP) should NOT be used as a first-line treatment for pertrochanteric fractures and are associated with unacceptably high complication rates (27% overall, with 12% requiring revision surgery), but may serve as a salvage option only when intramedullary nailing is absolutely contraindicated due to extreme fracture complexity or anatomic constraints. 1

Primary Treatment Recommendations

Stable Intertrochanteric Fractures

• Use a sliding hip screw (dynamic hip screw) as the preferred fixation method for stable intertrochanteric fractures 2, 3
• This represents the gold standard for stable fracture patterns 4

Unstable Intertrochanteric Fractures

• Cephalomedullary nail fixation is mandatory for unstable intertrochanteric fractures, including those with:
  • Lesser trochanter involvement or avulsion 3
  • Posteromedial comminution 3
  • Reverse oblique patterns 2, 3
  • Subtrochanteric extension 2, 3
• Intramedullary devices provide 1.78-fold greater axial load capacity compared to locking plates 4

When PFLCP Might Be Considered (Salvage Situations Only)

Extremely Limited Indications

PFLCP may be considered only when absolutely no other implant is deemed appropriate based on extreme comminution and fracture complexity that precludes intramedullary fixation 1

Critical Risk Factors for Failure

Patients must be counseled about high revision rates when PFLCP is used, particularly with:

• Active tobacco use (significantly correlates with complications, P = 0.020) 1
• Associated intracapsular femoral neck component (significantly correlates with complications, P = 0.006) 1
• Fractures with distal locking screw placement (all plate failures occurred at this location in biomechanical testing) 4

Clinical Outcomes Data

Complication Rates

• Overall complication rate: 27% (16/59 patients) 1
• Major complications requiring revision: 12% (7/59 patients) 1
• Minor complications (implant failure without revision): 15% (9/59 patients) 1
• Alternative series reported 45% complication rate including non-union, infection, and deformity 5

Union Rates (When Successful)

• Union achieved in 95-100% of cases that did not fail, typically at 9-18 weeks 6, 7, 5
• However, this excludes the substantial proportion requiring revision 1

Critical Technical Considerations If PFLCP Must Be Used

Surgical Technique

• Average operation time: 35.5 minutes 6
• Mean blood loss: 150 ml 6
• Mean incision length: 9 cm 6
• Achieve anatomic reduction with restoration of medial cortical continuity 8
• Target neck-shaft angle of approximately 130-135 degrees 8

Weight-Bearing Restrictions

• Clinicians must be extremely cautious about early weight-bearing with locking plates for unstable fractures 4
• Partial weight-bearing should be delayed until 6 weeks postoperatively or until union is achieved 5
• This contrasts with cephalomedullary nails, which allow immediate weight-bearing as tolerated 3

Common Pitfalls to Avoid

• Do not use PFLCP for pathologic fractures due to lack of bone healing potential 3
• Avoid in patients with active tobacco use given significantly increased complication rates 1
• Do not use when fracture has intracapsular neck component given 6-fold increased complication risk 1
• Never consider PFLCP equivalent to intramedullary fixation for unstable patterns—failure rates exceed 50% compared to cephalomedullary nails 3

The Bottom Line

The evidence strongly supports cephalomedullary nail fixation over PFLCP for unstable pertrochanteric fractures. 2, 3, 4 PFLCP should be reserved exclusively for rare salvage situations where intramedullary fixation is anatomically impossible, and patients must be explicitly counseled about the 27% complication rate and potential need for revision surgery. 1