TREATMENT OF INTERTROCHANTERIC FRACTURES

BY EXTERNAL FIXATION
M. SUBASI, C. KESEMENLI, A. KAPUKAYA, S. NECMIOGLU

In this study, we aimed to evaluate the results of

treatment of intertrochanteric fractures of the femur
by external fixation in 33 patients with an average
age of 65.9 years. Patients in the study had Evans stable type 1 intertrochanteric fractures and unstable
type 1 fractures that could be reduced to anatomical
or nearly anatomical position by closed manipulation
under fluoroscopy. The average follow-up period was
24 months (range, 12 to 40 months). There was no
mortality in the early postoperative period, but the
mortality within six month following surgery was
39%. Complete fracture healing was achieved in all
patients. The fixator was removed after an average of
94 days (75 to 130 days) at the outpatient clinic.
Varus malalignment of more than 20 and limb
shortening greater than 2 cm were noted in 3 patients.
Pin-tract infection was seen around 10 pins (7%).
Osteomyelitis was not noted in any patients.
Treatment of intertrochanteric fractures by external
fixation is simple and can be done under local anesthesia together with narcotic analgesic support. It
allows early mobilization, and implant removal is
easy. Therefore we think that external fixation is a
valuable alternative in high-risk geriatric patients.
Keywords : fmur ; intertrochanteric fracture ; external
fixation.
Mots-cls : fmur ; fracture pertrochantrienne ; fixation externe.

INTRODUCTION
Intertrochanteric fractures generally occur as a
result of low-energy trauma (such as simple falls)
in advanced age, whereas they are caused by highActa Orthopdica Belgica, Vol. 67 - 5 - 2001

energy trauma in young individuals (19). Increased

longevity, together with osteoporosis and senile
muscular insufficiency, may explain the increasing
number of patients with intertrochanteric fractures (7).
The main aims of the treatment of intertrochanteric fractures are to mobilize the patient in
a short period of time and to ensure union in the
appropriate position (8). These aims can only be
achieved by surgical methods. Implant failures and
malunions are frequently observed in osteoporotic
patients treated by internal fixation (8, 14). Many
internal fixations devices, such as angulated plates,
sliding nail-plates, gamma nails and intramedullary
hip screws have been used.
Intertrochanteric fractures mostly occur in
patients with poor general condition who cannot
undergo general anesthesia or who are not fit for an
invasive intervention owing to diabetes, atherosclerotic heart disease or chronic obstructive pulmonary disease. Treatment of such patients by
long-term immobilization following internal fixation is not possible owing to the risk of decubitus
ulcers, pneumonia, urinary tract infections, deep
venous thrombosis and cardiopulmonary complications (7, 8, 10, 11, 12).
Anderson et al. used external fixation for the
treatment of fractures of the intertrochanteric

Department of Orthopedic Surgery, University of Dicle,

Diyarbakir / Turkey.
Correspondence and reprints : Mehmet Subasi, Dicle University Department of Orthopedic Surgery, Diyarbakir / Turkey.
E-mail : [email protected].

TREATMENT OF INTERTROCHANTERIC FRACTURES

469

region for the first time in 1943 (1). Scott also used
it because of its advantages such as short operation
time, early postoperative mobilization, preservation of the fracture hematoma and early union of
fracture (3, 5, 9, 20).
We retrospectively evaluated the results in cases
that were treated by external fixation since 1994 for
intertrochanteric fractures, to assess the value of
this treatment method in certain patient groups.
MATERIAL AND METHODS
Thirty-three patients, 19 males and 14 females, with
intertrochanteric fracture of the femur were treated by
external fixation between 1994 and 1999. Fifteen
patients had right and 18 had left intertrochanteric fractures. The mean age of the patients was 65.9 (47 to 90)
years. Eight fractures were the result of traffic accidents
and 25 of falls. The patients had high surgical and anesthetic risk factors for an open surgical procedure or for
extended anesthesia because they had more than one
accompanying disease. Seventeen patients had ischemic
cardiac disease, 18 pulmonary disease, 10 diabetes mellitus, 14 hypertension, 5 heart failure, and 9 had cerebral
dysfunction. The average time of hospitalization was
2.8 days (0 to 21 days). External fixation was used in
patients with Evans stable type 1 intertrochanteric fractures and unstable type 1 fractures which could be
reduced to anatomical or nearly anatomical position by
closed methods under fluoroscopic control.
The patients were operated on average 5.7 days (2 to
11 days) following admission. During the operation, 3
patients had undergone epidural, 21 spinal, 6 general
and 3 local anesthesia together with narcotic analgesic
support. The average time of operation was 30 (20 to 45)
minutes.
The patient was placed on an orthopedic table, and
reduction was checked by fluoroscopy. Reduction was
achieved by moving the limb into 20-30 abduction and
10-15 internal rotation on the fractured side. A 3-mm
guide wire was then introduced under fluoroscopy into
the head with the appropriate neckshaft angle and
anteversion angle. The guide wire was introduced using
a manual perforator.
The first pin was inserted through a small incision at
the base of the greater trochanter, across the fracture site
into the femoral neck. One or two more pins were inserted .The tips of the pins were at a 10 - mm distance from
the joint line (fig. 1). The proximal part of the external
fixator allows the insertion of the proximal Shanz pins at

c
Fig. 1. The right hip of a 60-year-old male patient.
1a) Preoperative xray.
1b) Anteroposterior xray with external fixation 75 days
postoperatively.
1c) Anteroposterior xray 85 days postoperatively (after fixator removal).

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M. SUBASI, C. KESEMENLI, A. KAPUKAYA, S. NECMIOGLU

Fig. 2. The left hip of a 55-year-old male patient.

2a) Preoperative anteroposterior xray.
2b) Anteroposterior xray with external fixation postoperatively.
2c) Anteroposterior xray one year postoperatively.

a 135 angle to the stem of the fixator. Three 5-mm pins

were inserted into the middle third of the shaft of the
femur. In order to increase the range of motion, the knee
was put into flexion at 90 during insertion of the pins.
A final check by fluoroscopy was made.
Active hip and knee exercises were started on the first
postoperative day. The patients were mobilized on the
second or third day with partial weight-bearing using a
walker ; they were discharged on average eight days (4
to 20 days) after operation.
Outpatient clinic evaluations were made at 15-day
intervals, and knee movements, pin-tract infection and
consolidation of the fracture were evaluated by radiography. The fixators were removed after an average of
94 (75 to 130) days under outpatient clinic conditions.
The patients were seen for evaluation at 2-month intervals.

RESULTS
The mean follow-up period was 24 months (1240 months). Mortality three months following
surgery was 15%. The six-month mortality was
39%. There was no mortality in the early postoperActa Orthopdica Belgica, Vol. 67 - 5 - 2001

ative period. In several cases, relatives of hemodynamically unstable patients did not allow the operation when informed about the possibility of death
during operation, and they took the patient home
without any operation.
Twenty of the 24 surviving patients were evaluated clinically and radiographically. On AP pelvic
xrays, varus deformity and clinically, the distance
between the anteriorsuperior iliac spine and the
medial malleolus and between the umbilicus and
the medial malleolus were evaluated, and the
length discrepancies between extremities were
recorded.
Two patients could walk with crutches (one
patient was in the same situation before the fracture), 10 could walk with a single crutch (six
patients were in the same situation before the fracture) and 8 could walk without any support at the
last check-up (fig. 2). Fifteen of 20 patients (75%)
regained their previous walking ability.
Malunion was detected in 3 patients (15%).
Shortening greater than 2 cm was noted in these
patients at the latest follow-up as a result of varus

TREATMENT OF INTERTROCHANTERIC FRACTURES

malunons. Regarding knee motion, all patients had

limited flexion in the postoperative period ; however, recovery was seen during the follow-up. At
the final evaluation, the mean range of motion of
the knee was 98 (range, 70 to 120). Three
patients (15%) had less than 900 range of motion of
their knees.
Pin-tract infection was observed around 10 pins
(7%). The patients who had grade I (soft tissue
inflammation) and II (soft tissue infection) pin tract
infections, were treated with wound dressing and
antibiotic medication. None of the cases developed
osteomyelitis. No material failures occurred.
DISCUSSION
Intertrochanteric femoral fractures are one of the
most important fractures of the lower extremity.
The prevalence of hip fractures is increasing owing
to the increase in life expectancy and the inefficacious treatment of osteoporosis, which still is the
basic factor for such fractures (8, 14). Owing to
advanced age, the first goal is patient survival. The
main objective of the treatment is to minimize the
complications related to age and immobilization.
This can be achieved using internal or external
fixation.
The most efficient conservative treatment
method is the modified Hamilton Russell traction.
It requires that the patient should be hospitalized
for at least 2 to 3 months, and complications may
be seen (8).
Open reduction and internal fixation of trochanteric fractures is the routine procedure, but in
patients at risk with accompanying pathology, such
as ischemic cardiac disease, chronic obstructive
pulmonary disease, diabetes mellitus, or severe
anemia, there is a high risk of anesthetic or postoperative complications (7, 8, 12). Many internal
fixations, such as angulated plates, sliding nailplates, gamma nails and intramedullary hip screws
have been used. A sliding hip screw is the implant
of choice for the treatment of both stable and unstable intertrochanteric fractures (13, 18). Use of this
implant for intertrochanteric fracture stabilization
is associated with a 4% to 12% incidence of loss of
fixation (18). Theoretical advantages of intra-

471

medullary hip screws and gamma nails are both

technical and mechanical compared to the sliding
hip screw. Most studies comparing these devices to
sliding hip screws have found no differences with
respect to surgical time, duration of hospital stay,
infection rate or wound complications, implant
failure, screw cut out, or screw sliding. Patients
treated with an intramedullary hip screw, however,
are at increased risk for femoral shaft fracture at the
nail tip and the insertion sites of the distal locking
bolts. The prevalence of diaphyseal fractures has
been reported to range from 0% to 17% (6, 13, 18).
Furthermore, since the patient cannot walk with
full weight bearing until union is achieved following internal fixation, rapid rehabilitation cannot be
achieved. The difficulty and delay of rehabilitation
in these patients who have systemic problems and
a decreasing will and joy to survive aggravates the
problems and leads to an increase in the early mortality rates (10).
Total hip arthroplasty may be indicated in
patients with intertrochanteric fracture and preexisting osteoarthritis. However, this may not be possible owing to the general condition of the patient
whereas external fixation may be used even in
hemodynamically unstable patients. Secondary
prosthetic arthroplasty may be performed after
removing the external fixation, if the cultures are
negative after antibiotic suppression, and after a
minimum period of 15 days follow-up. If there is a
risk for infection, a Girdlestone arthroplasty may
be required but this did not occur in any of our
cases. External fixation in intertrochanteric fractures can be considered to be a semi-conservative
method (10). It may be a reasonable alternative for
patients who are of advanced age, have a poor general condition and cannot tolerate long operations (12). With external fixation, the average
anaesthesia time was 30 minutes including reduction and percutaneous application compared with
72 to 100 minutes for open reduction and internal
fixation procedures (7, 10). External fixation technique gives shorter anesthesia time, minimal surgical trauma, and minimal blood loss. This is a very
important point to stabilize the general medical
condition in such elderly patients and to prevent
postoperative complications such as urinary tract
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M. SUBASI, C. KESEMENLI, A. KAPUKAYA, S. NECMIOGLU

infections, pneumonia, decubitus ulcers, and deep

wound infection (3, 10). These postoperative complications have been associated with increased
mortality rates (10, 16, 17). External fixation preserves the fracture hematoma, which is of importance for union. Complete fracture healing
occurred in all our patients. The average time to
complete union was 94 days as compared to 4 to
5 months after open reduction and internal fixation
procedures (2, 10). Christodoulou et al. have compared the results in patients who were treated by
external fixation or internal fixation. According to
their study, in the external fixation group, operating
time was 35 minutes, hospital stay was 6 days,
varus deformity was detected in 5 patients. Three
of them were corrected by fixator. They have
reported operating time as 75 minutes, hospital stay
16 days, varus deformity in three patients in the
internal fixation group (7). The average hospital
stay in our cases was 8 days.
Possible complications of treatment of
intertrochanteric fractures using external fixation
are pin-tract infection, varus deformity and shortening. However, the literature review shows that
such complications occur with a low rate. The
advantage of external fixation in unstable
intertrochanteric fractures is that it is possible to
correct these deformities, especially in the first
postoperative days, without open surgical intervention (7). The rate of infection varies between 2 and
25% (4, 10, 15). We observed 10 (7%) pin-tract
infections. The patients were treated with wound
dressing and systemic antibiotic medication.
Thermal necrosis caused by high-speed drilling
may lead to infection (20) ; we therefore used
manual drills. Most of our patients applied dressings themselves at home and did not pay attention
to sterility as required. Malunion was detected in
three patients (15%). As a result of varus malunion,
more than 2-cm limb shortening was noted in these
patients at the latest follow-up. Regarding knee
motion, all patients had limited flexion in the postoperative period probably as a result of the fixation
of the soft tissue ; however, improvement was identified during follow-up (10).
In conclusion, external fixation of intertrochanteric fractures is less invasive than internal
Acta Orthopdica Belgica, Vol. 67 - 5 - 2001

fixation and does not evacuate the fracture

hematoma, which is of great importance for union.
It is easily applied in a short surgical session and
can be performed under local anesthesia when necessary. It allows early mobilization, and the fixator can be removed easily under outpatient conditions. Pin - tract infection which can be considered
as a disadvantage can be prevented or minimized
by introducing the nails with a manual perforator
and appropriate pin-tract care. Therefore, it may be
considered to be an alternative treatment modality
for high-risk geriatric patients with selected fracture types. This technique is simple, safe and can
be performed under regional and even local anesthesia together with narcotic analgesic support
when required.
REFERENCES
1. Anderson R., Mckibbin W. B., Burgess E. Intertrochanteric
fractures. J. Bone Joint Surg., 1943, 25, 153-168.
2. Barquet A., Francescoli L., Rienzi D., Lopez L.
Intertrochanteric subtrochanteric fractures : Treatment
with the long Gamma nail. J. Orthop. Trauma, 2000, 14,
324-328.
3. Badras L., Skretas E., Vayanos E. D. Traitement des fractures pertrochantriennes par fixateur externe. Rev. Chir.
Orthop., 1997, 84, 461-465.
4. Barros J. W., Ferreira C. D., Freitas A. A., Farah S.
External fixation of intertrochanteric fractures of the
femur. Int. Orthop., 1995, 19, 217-219.
5. Buckley J. R., Caiach S. M. External fixation in comminuted upper femoral fractures. Injury, 1993, 24, 476-478.
6. Butt M. S., Krikler S. J., Nafia S., Ali M. S. Comparison of
dynamic hip screw and gamma nail : A prospective, randomized, controlled trial. Injury, 1995, 26, 615-618.
7. Christodoulou N. A., Sdrenias C. V. External fixation of
select intertrochanteric fractures with single hip screw.
Clin. Orthop., 2000, 381, 204-211.
8. Dhal A., Varghese M., Bhasin V. B. External fixation of
intertrochanteric fractures of the femur. J. Bone Joint
Surg., 1991, 73-B, 955-958.
9. Dhal A., Singh S. S. Biological fixation of subtrochanteric
fractures by external fixation. Injury, 1996, 27, 723-731.
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Treatment of intertrochanteric fractures by external fixation. Bull. Hosp. Joint. Dis., 2000, 59, 131-135.
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by external fixation. Orthopedics, 1985, 8, 769-774.
12. Haentjens P., Casteleyn P. P., De Boeck H., Handelberg F.,
Opdecam P. Treatment of unstable intertrochanteric and

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Little Brown, Boston, 1993, pp. 338-339.
Kamble K. T., Murthy B. S., Pal V., Rao K. S. External
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SAMENVATTING
M. SUBASI, C. KESEMENLI, A. KAPUKAYA,
S. NECMIOGLU. Uitwendige fixatie als behandeling
van intertrochantere fracturen.
De resultaten van behandeling van intertrochantere fracturen van het femur bij middel van uitwendige fixatie
worden bestudeerd in 33 risico-patinten met een
gemiddelde leeftijd van 65.9 jaar. Het ging om stabiele
en instabiele type I Evans breuken, gereduceerd tot anatomische of aanvaardbare stand onder korte anaesthesie
of sedatie met controle van beeldversterker. De gemiddelde opvolging bedroeg 24 maand (12-40 maand). Er
was geen onmiddellijk postoperatieve mortaliteit, maar
er was een 6 maand mortaliteit van 39%. Fractuurheling
was de regel. De uitwendige fixatie bleef terplaatse
gedurende gemiddeld 94 dagen (75-130) en werd ambulant verwijderd op de raadpleging. Bij drie patinten

werd een varus kanteling van meer dan 20 en een

verkorting van meer dan 2 cm gevonden. Pin-tract infectie kwam voor rond 10 pinnen (7%). Geen enkel geval
van osteomyelitis.
De behandeling van intertrochantere fracturen met een
uitwendige fixator is eenvoudig, kan onder sedatie en
lokale anesthesie. Vroegtijdige mobilisatie is mogelijk
en verwijdering van de fixator is simpel. Voor de schrijvers is het een valabel alternatief bij hoog-risico bejaarden.
RSUM
M. SUBASI, C. KESEMENLI, A. KAPUKAYA,
S. NECMIOGLU. Traitement des fractures pertrochantriennes par fixateur externe.
Les auteurs ont tudi, chez 33 patients gs en
moyenne de 65,9 ans, les rsultats du traitement par
fixation externe de fractures pertrochantriennes du
fmur. Il sagissait de fractures pertrochantriennes stables de type Evans 1 ou instables de type 1, quil tait
possible de rduire en position anatomique ou quasi
anatomique par manipulation foyer ferm sous contrle radioscopique. Le suivi moyen a t de 24 mois
(extrmes : 12 et 40 mois). Il ny a eu aucun dcs dans
le post-opratoire immdiat, mais la mortalit six mois
tait de 39%. La consolidation complte a t obtenue
dans tous les cas. Le fixateur a t enlev en ambulatoire, en moyenne aprs 94 jours (extrmes : 75 et
130 jours). Une dsaxation en varus de plus de 20 et un
raccourcissement du membre suprieur 2 cms ont t
relevs chez trois patients. Une infection sest produite
sur 10 broches (7%) mais na entran aucune ostomylite.
Le traitement des fractures pertrochantriennes par fixateur externe est simple et peut se faire sous anesthsie
locale, sous couverture analgsique. Il permet la mobilisation prcoce, lablation du matriel est aise. Les
auteurs considrent que le fixateur externe est un traitement valable chez les patients griatriques haut risque.
EDITORIAL NOTE
At first look this is a disturbing approach to a common problem in the elderly, which seems to ignore the
recent improvements in anaesthetic techniques, surgical
skills and fixation methods.
Very often the mental condition of the severely ill
elderly patient with a trochanteric fracture jeopardizes

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M. SUBASI, C. KESEMENLI, A. KAPUKAYA, S. NECMIOGLU

the succesful application and continuation of external

fixation throughout union.
After reading this article and surveying the scarse
literature on the subject, the editorial board decided to
publish this original study. Indeed, external fixation

Acta Orthopdica Belgica, Vol. 67 - 5 - 2001

might be the single possible solution for those rare

patients that are considered unfit for open surgery with
blood loss and prolonged anesthesia, keeping in mind
the unavoidable pin tract complications and the occasional malunion.