Cortical Support in Unstable Intertrochanteric Fracture without Fixation of Posteromedial Fragment

Abstract

Background: It is well known that the posteromedial (PM) buttress plays an important biomechanical role in ensuring stability in unstable intertrochanteric (INT) fractures. However, the necessity for the fixation of PM fragments remains controversial. This study aims to assess surgical outcomes, including fracture site collapse and fixation failure, when PM fragments are not fixed in patients who are treated with intramedullary nailing for unstable INT fractures with large PM fragments. Methods: We retrospectively analyzed 658 hip fracture surgeries performed at a tertiary referral hospital between September 2011 and August 2021. The patients who had unstable INT fractures without fixation of large PM fragments and who were followed up for a minimum of 6 months were included. In 157 patients (157 hips), surgical outcomes, such as fracture site collapse, fixation failure, and posttraumatic osteonecrosis of the femoral head (ONFH), were assessed. The patients with an intramedullary reduction on lateral radiographs were classified as the non-cortical support (non-CS) group, and patients with extramedullary or anatomical reduction were classified as the CS group. Results: Among 157 patients (157 hips), fracture site collapse occurred in 64 patients (40.8%), fixation failure in 5 (3.2%), and posttraumatic ONFH in 2 (1.3%). Reoperation, such as conversion to hip arthroplasty, was performed in 4 patients (2.5%). In the comparative analysis between the CS and non-CS groups, fracture site collapse occurred significantly more frequently in the non-CS group (48.7%) compared to the CS group (32.9%) (p = 0.044). There was no significant difference in fixation failure, posttraumatic ONFH, and reoperation (p > 0.05) between the groups. Conclusions: In unstable INT fractures without fixation of the PM fragment, the incidence of fixation failure was 3.2% and significantly associated with inadequate reduction, especially when CS was absent. The surgeon should pay attention to achieving optimal CS with appropriate reduction status of the fracture, which is critical in determining the surgical outcome.