Abstract:
Intertrochanteric fractures are common injuries around the hip, especially among the elderly.
With the rising incidence of these injuries, they are expected to double by 2050. Incidence rates
are higher in females than males and in white patients than black African patients. Osteoporosis
weakens the local trochanteric anatomic support leading to an increased susceptibility to fractures.
Disruption of the posteromedial calcar region results in fracture instability. Optimal lag screw
position and fracture reduction are significant determinants for postoperative outcomes. The
tip apex distance and reduction criteria determine lag screw cut-out risk and fracture reduction
quality, respectively. A calcar-referenced tip apex distance is comparable if not better than the tip
apex distance in predicting cut-out risk. Optimal reduction is in slight valgus, a positive medial
cortex apposition and smooth anterior cortex apposition.
High mortality rates are observed with non-surgical treatment. Surgical management is therefore
the gold standard for intertrochanteric fractures. Treatment options are categorised into
extramedullary fixation, intramedullary fixation and proximal femur replacement. They include
the dynamic hip screw (DHS), cephalomedullary nails (CMN) and arthroplasty. Although still
in use, the proximal femur locking plate is falling out of favour due to high complication rates.
Fracture stability and pattern influence the treatment choice. There is, however, a growing use
of CMNs which has been attributed to surgical training background. Modification of older CMN
designs has improved treatment outcomes. Systematic meta-analyses of randomised controlled
trials (RCTs) do not show superiority of one treatment option over another; therefore, there is no
consensus on the best treatment choice.
The proximal femur nail antirotation (PFNA) has better outcomes compared to other fixation
options with respect to intraoperative blood loss and Harris hip scores. As a group, CMNs have
a better 120-day postoperative quality of life compared to the DHS. No significant difference in
complications has been found between treatment options. In light of the anticipated increased
incidence of intertrochanteric fracture, more work is needed in planning national resource
allocation, devising preventative methods and improving clinical interventions in South Africa.
