Unstable Intertrochanteric Femur Fractures: Is There a Consensus on Definition and Treatment in Germany?

• Published in: Clinical orthopaedics and related research 2013-09, Vol.471 (9), p.2831-2840
• Main Authors: Knobe, Matthias, Gradl, Gertraud, Ladenburger, Andreas, Tarkin, Ivan S., Pape, Hans-Christoph
• Format: Article
• Language: English
• Subjects: Bone Nails; Bone Screws; Consensus; Conservative Orthopedics; Femur - surgery; Fracture Fixation - methods; Germany; Health Care Surveys; Hip; Hip Fractures - diagnosis; Hip Fractures - surgery; Hip Joint - surgery; Humans; Medicine; Medicine & Public Health; Orthopedics; Sports Medicine; Surgery; Surgical Orthopedics; Symposium: Tscherne Festschrift; Treatment Outcome
• ISSN: 0009-921X; 1528-1132
• DOI: 10.1007/s11999-013-2834-9

Background Extramedullary and intramedullary implants have improved in recent years, although consensus is lacking concerning the definition and classification of unstable intertrochanteric fractures, with uncertainties regarding treatment. Questions/purposes We conducted a national survey of practicing chairpersons of German institutions to determine current perspectives and perceptions of practice in the diagnosis, management, and surgical treatment of unstable intertrochanteric fractures. Methods Between January and February 2010, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 26-question web-based survey regarding three broad domains: fracture classification and instability criteria, implants and surgical treatment algorithms, and timing of operations. Response rate was 42%. Results There was a clear preference for use of the AO/OTA fracture classification with geographic variations. Absence of medial support was considered the main criterion for fracture instability (84%), whereas a broken lateral wall and detached greater trochanter were considered by 4% and 5% of the respondents, respectively, to determine instability. Two percent routinely fixed unstable intertrochanteric fractures with extramedullary devices. Ninety-eight percent of German hospitals reportedly perform surgery within 24 hours after admission. Time to surgery was dependent on hospital level, with more direct surgeries in Level I hospitals. Conclusions Despite varying opinions in the literature in recent years, we found some instability criteria (lateral wall breach, a detached greater trochanter) played a minor role in defining an unstable intertrochanteric fracture pattern. Despite recent meta-analyses suggesting clinical equivalence of intra- and extramedullary implants, few respondents routinely treat unstable intertrochanteric fractures with extramedullary plates. Additional studies are required to specify the influence of fracture characteristics on complication rate and function and to establish a classification system with clear treatment recommendations for unstable intertrochanteric fractures. Level of Evidence Level V, expert opinion. See the Instructions for Authors for a complete description of levels of evidence.