The prevention of deformity fractures the · The prevention of deformity in intertrochanteric...

$: The prevention of deformity fractures the · The prevention of deformity in intertrochanteric fractures of the femur E. N. WARDLE M.Ch.Orth., F.R.C.S. Department of Orthopaedic Surgery,$
Postgrad. med. J. (June 1967) 43, 385-399.

The prevention of deformityin intertrochanteric fractures of the femur

E. N. WARDLEM.Ch.Orth., F.R.C.S.

Department of Orthopaedic Surgery,University of Liverpool

ALTHOUGH the first recorded mention of internalfixative apparatus for the treatment of inter-trochanteric fractures was made by Preston in1914, it was not until the decade 1935-45 thatdevices of this kind came into common use. Thissudden interest probably arose because of thegreat general benefit which patients with sub-capital fractures of the femur were seen to obtainfrom the same type of procedure.Among the many articles published subsequently

all those which contain radiographs of any lengthyseries of patients show examples of intertrochan-teric fractures which have collapsed into varusdeformity during their union; and in many in-stances disruption of the metal device also (Murray& Frew, 1949; Boyd & Griffin, 1949; Evans,1951; McLaughlin & Garcia, 1955; Taylor,Neufeld & Nickel, 1955; Foster, 1958). The illus-tration (Fig. 1) displays this type of collapse anddisruption. A study of these deformities shows thatthey are nearly always associated with inter-trocanteric fractures in which the lesser trochanteris separated, or at least involved in the fractureline. Several authors have referred to this par-ticular type of intertrochanteric fracture asunstable.

In the years which have passed since the des-cription by Taylor, Neufeld & Jantzen (1944) ofthe nail plate which bears the name of Nuffield,much time and ingenuity have been spent indesigning internal fixative apparatus strong enoughto prevent such deformity occurring, with par-ticular reference to early movement and weight-bearing for these elderly patients (McLaughlin,1947; Hafner, 1951; McLaughlin & Garcia, 1955;Holt, 1963; Sarmiento, 1963). During this period,on the contrary, little interest has been shown inthe possibility that the cause of this varusdeformity is muscle imbalance, not faulty appara-tus. In 1962, together with Murray Brookes(Brookes & Wardle, 1962), I drew attention to thechanges in shape of the upper femur which muscleimbalance can produce when the bone is softened

from any cause. It was calculated that in order toprevent ilio-psoas force producing valgus de-formity in the femoral neck an opposed 'varus-producing' gluteal force required to be applied tothe greater trochanter in the ratio ilio-psoas, five:gluteii, three. So that in any intertrochantericfracture until union is present, unbalanced glutealmuscular force can act on the proximal fragmentin proportion to the disintegration which thefracture has produced in the trochanter and neckof the femur; and in those fractures where thelesser trochanter is completely separated the wholeof the abductor force, quite unbalanced, is actingon the proximal fragment. It is of some interest tonote that McLaughlin in his original paper in 1947,describing his apparatus for fixation of thesefractures barely mentions the occurrence of varusdeformity; but in writing with Garcia in 1955 hecondemns his original apparatus out of hand onaccount of the high rate of post- operativedeformity, and describes yet a further model inthe effort to prevent this.

Clinical materialCertain groups of patients have been selected.(a) Five representative patients in whom an

intertrochanteric fracture associated with avulsionof the lesser trochanter has been reduced and fixedby a nail and plate. All of them illustrate collapseinto deformity, but they show that this may takedifferent forms. Where one-piece apparatus of theNeufeld type has been used the varus deformity isassociated either with bending of the nail or dis-ruption of the screws and plate from the femoralshaft. Where two-piece apparatus has been usedthere is much less tendency for the plate or screwsto alter their position in relation to the distal frag-ment but the deformity of the head and neckoccurs around the nail which is thus left protrud-ing into the hip joint. Occasionally with the earlierforms of two-piece apparatus the holding boltwould unscrew from the nail and deformity occursaround the bracket. It is clear from comparison of

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E. N. Wardle

the first and last films in any of these fracturesthat the final deformity often approximates closelyto that present before the fracture was reduced(Figs. 2-5).

(b) From a consecutive series of forty inter-trochanteric fractures coming under my care in theperiod January 1962 to January 1966, fifteen havebeen chosen in all of whom the fracture was eitherassociated with complete separation of the lessertrochanter as a fragment, or the fracture line haspassed directly through the lesser trochanter. Infour of these patients at the time of reduction oftheir fracture and its fixation with a nail and platethe lesser trochanter was fixed to the femoral shaftby means of a screw. In eleven of them, at thetime of reduction and fixation, the attachments ofthe gluteus medius and minimus to the greatertrochanter were divided (Table 1). There was no

TABLE 1Fifteen patients with intertrochanteric fractures

Treatment and Age Date of fracture Date of fixationname

Treated by screw fixationMiss D.H. 59 2 Jan. 1962 9 Jan. 1962Mrs F.P. 81 13 Jan. 1961 17 Jan. 1961Mrs E.F. 90 13 Aug. 1961 22 Aug. 1961Mrs M.G. 65 3 Nov. 1961 14 Nov. 1961

Treated by gluteal sectionMrs M.C. 56 16 Jan. 1962 18 Jan. 1962Mrs S.M. 78 4 Feb. 1962 6 Feb. 1962Mr W.F. 78 26 Dec. 1962 30 Dec. 1962Mr R.W. 83 29 Dec. 1962 1 Jan. 1963Mrs E.W. 77 1 Jan. 1963 15 Jan. 1963Mr J.S. 82 23 Jan. 1963 29 Jan. 1963Mr H.T. 69 11 Dec. 1963 19 Dec. 1963Miss D.B. 53 3 Dec. 1964 9 Dec. 1964Mrs G.S. 61 18 Dec. 1964 21 Dec. 1964Miss B.B. 76 9 April 1965 19 April 1965Mrs E.R. 65 4 Jan. 1963 8 Jan. 1963

operative mortality amongst these patientsalthough several of them have since died fromnatural causes. All of them survived a sufficientlength of time to walk upon the injured leg and todemonstrate firm bony union at the fracture site.In none of them did significant varus deformityappear and in no case did the internal fixativeapparatus break down. Table 1 shows that in age,sex and general condition they were fully repre-sentative of this type of intertrochanteric fractureseen routinely in any orthopaedic service. None ofthem was allowed to bear weight until the 6th post-

operative week but they were all encouraged inactive non-weight bearing movement of the in-jured limb as soon as they wished and all of themwere sitting out of bed within a week from thetime of their operation. It was notable that all ofthem established a range of active abduction at theinjured hip with ease and that all the hips werestable as soon as weight-bearing was commenced(Figs. 6-12).DiscussionAssuming that the deformity occurring during

the union of intertrochanteric fractures, as illus-trated, arises because of the disturbance of thenormal balance of muscular forces around the hip-joint, and recognizing that this force is sufficientlypowerful to bend metal nails and break or disruptscrews, two possible methods of prevention presentthemselves. First of all a re-balance of the mus-cular power by the direct re-attachment of thelesser trochanter in its normal position. Secondly are-balance of muscular power by the deliberatetemporary obliteration of the abductor pull. Radio-graphs (Figs. 6-12) illustrate that both thesemethods are effective. The first, re-fixation of thelesser trochanter, is technically difficult and pro-longs the operative time in a patient who is usuallyaged and in a poor state of general health. Eithera guide has to be positioned through the upperfemoral shaft into the lesser trochanter by X-raycontrol, which is very time-consuming; or a con-siderable exposure of the hip-joint area is requiredthrough a posterior type of approach. This addsgreatly to the general upset of an aged patient.The second, temporary ablation of the attach-ments of gluteus medius and minimus to thegreater trochanter is in effect a tenotomy. It maybe simply performed through a 2 in. extension ofthe lateral approach commonly used for nail-plateoperations. As in tenotomies in other parts of thebody, union is certain and effective muscle powerrapidly restored in a few weeks' time. Such atemporary ablation of the abductor muscle actionat the hip-joint necessarily prevents weight-bearingon the injured limb for a period of 4-5 weeks andthe results are sufficiently and consistently good toraise the question of whether early weight-bearingis of any value at all in the rehabilitation of theseelderly patients. None of the patients here recordedhas suffered in any way from this prevention ofweight-bearing. Such a prohibition is not to beconfused with the establishment of early move-ment both at the knee and the hip. Two points ofinterest arise here. First of all that the patientstreated by gluteal section have developed activenon - weight- bearing movements as rapidly aspatients whose fractures have simply been nailedand plated. Secondly, the movement of active

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FIG. 3. Mr G.J. (a) A.P. and lateral views of intertrochanteric fracture, 1962. (b) A.P. and lateral views of deformity, 1964.

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FIG. 8. Mr J.S. (a) A.P. and lateral views of an intertrochanteric fracture, January 1963. (b) A.P. and lateral viewsof fracture united without deformity 6 months after reduction, fixation and gluteal section.



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FIG. 12. Mrs E.R. (a) A.P. and lateral views of an intertrochanteric fracture, 4 January 1963. (b) A.P. and lateralviews of union without deformity, 20 October 1965.

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Intertrochanteric fractures of the femur 399

flexion at the hip-joint is the one most likely tocause the screw-threaded bolt in the older type ofnail plate to undo itself. This movement of activeflexion of the hip, done as a deliberate exercise, isthe one which should be delayed longest of all.Much less emphasis should be placed on havingthese patients walk early than has previously beenthe case although every effort should be made tohave them sitting out of bed in a chair as soon aspossible.

Summary(1) Evidence is produced to show that varus

deformity in intertrochanteric fractures is pro-duced by the muscle imbalance inherent in the frac-tures in which the insertion of the psoas muscle isinvolved.

(2) This imbalance can be corrected by simpledetachment of the gluteii from the greater tro-chanter which is effective for sufficient time toallow union without deformity and produces nodisability.

(3) It is suggested that further strengthening ofinternal fixative apparatus defeats its own object.

(4) However strong the apparatus, earlyweight-bearing before bony union is firm causesthe muscles to exert a force which no metal canstand.

AcknowledgmentsI am most grateful to my colleague, Professor Robert Roaf,

for his criticism and encouragement. I offer my gratefulthanks to Mr H. O. Williams who has allowed me to includeseveral of his patients in Figs. 2 and 3; and to my registrar,Mr David Habib, who collected the case notes and X-rayphotographs of my own patients.

References

BOYD, H.B. & GRIFFIN, L.L. (1949) Classification and treat-ment of trochanteric fractures. Arch. Surg. 58, 853.

BROOKES, M. & WARDLE, E.N. (1962) Muscle action and theshape of the femur. J. Bone Jt Surg. 44-B, 398.

EVANS, E.M. (1951) Trochanteric fractures: A review of110 cases treated by nail-plate fixation. J. Bone Jt Surg.33-B, 192.

FOSTER, J.C. (1958) Trochanteric fractures of the femurtreated by the Vitallium McLaughlin nail and plate.J. Bone Jt Surg. 40-B, 684.

HAFNER, R.H.V. (1951) Trochanteric fractures of the femur.A review of 80 cases with a description of the 'low-nail'method of internal fixation. J. Bone Jt Surg. 33-B, 513.

HOLT, E.P. (1963) Hip fractures in the trochanteric region:treatment with a strong nail and early weight bearing.J. Bone Jt Surg. 45-A, 687.

MCLAIJGHLIN, H.L. (1947) An adjustable internal fixationelement for the hip. Amer. J. Surg. N.S. 73, 150.

MCLAUGHLIN, H.L. & GARCIA, A. (1955) An adjustablefixation device for the hip. Amer. J. Surg. 89, 867.

MURRAY, R.C. & FREW, J.F.M. (1949) Trochanteric frac-tures of the femur. J. Bone Jt Surg. 31-B, 204.

PRESTON, M.E. (1914) New appliance for the internalfixation of fractures of the femoral neck. Surg. Gynec.Obstet. 18, 260.

TAYLOR, G.M., NEUFELD, A.J. & JANTZEN, J. (1944) Internalfixation for intertrochanteric fractures. J. Bone Jt Surg.26, 707.

TAYLOR, G.M., NEUFELD, A.J. & NICKEL, V.L. (1955)Complications and failures in the operative treatment ofintertrochanteric fractures of the femur. J. Bone Jt Surg.37-A, 306.

SARMIENTO, A. (1963) Intertrochanteric fractures of thefemur. 150-degree angle nail-plate fixation and earlyrehabilitation. J. Bone Jt Surg. 45-A, 706.



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