Analysis of Intertrochanteric Hip Fractures Failure – What do Trauma Surgeons Agree Upon?

Yoram Weil Daniel Izrael Amal Khoury Rami Mosheiff Meir Liebergall
Orthopaedics, Hadassah Hebrew University Hospital, Jerusalem, Israel

Background: Intertrochanteric fractures (ITF) are among the commonest pathologies treated by orthopaedic surgeons. Fixation failures are reported to occur between 5-16% according to recent literature. However, the definitions, cause and analysis remain controversial. The aim of the study was to identify risk factors for fixation failure Among different surgeons. Methods: Between 2008-2015 169 cases of ITF were identified as fixation failures. 100 cases with complete radiographic follow up were assessed by 4 experienced fellowship trained trauma surgeons. Out of them 70 were fixed by Percutenous Compression Plate (PCCP) and 30 by a cephalomedullary nails. The surgeons were asked to fill in the details regarding AO classification, identify posteromedial comminution, lateral wall fracture, implant preference (nail or plate), quality of reduction (by a score and specifically for the calcar), technical errors, allow or restrict postoperative weightbearing, and eventually type of failure. Radiographs included preoperative , interaoperative, immediate and late posteorpative. The Kendall Tau non-parametric test was used to assess agreement between the four observers. With this test a nonsignificant (p > 0.05) value was considered as an agreeable parameter.

Results: Of all parameters the following were considered to be with an agreement between the surgeons: Preoperative AO (31a1 to 3) classification, posteromedial communition after Reduction, broken lateral wall (after reduction), implant preference, postoperative reduction quality of the calcar and the fracture, weight bearing recommendation and the existence of a surgical error. The observers failed to agree about the intraoperative AO classification, intraoperative reduction quality and the type of failure observed.

Conclusions: Intraoperative decision making in treating trochanteric fractures may be more complicated than it seems. Although significant variation among surgeons can be seen, experienced trauma surgeons do agree among crucial factors affecting surgical outcome including fracture classification, reduction quality, preferred implant and the existence of surgical errors.