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Intertrochanteric Fractures Thomas A.

Russell INTRODUCTION Pertrochanteric fractures are those occurring in the region extending from the extracapsular basilar neck region to the region along the lesser trochanter before the development of the medullary canal. Intertrochanteric and peritrochanteric are generic terms for pertrochanteric fractures. Injury creates a spectrum of fractures in this proximal metaphyseal region of bone, with damage to the mechanically optimized placement of intersecting cancellous compression and tensile lamellae networks and the weak cortical bone with resulting displacement from the res pective attachment of muscle groups to the fracture fragments and an adjacent high mobility joint. These structures are subject to multiplanar stresses after surgical repair. This region of the femur shares many common biomechanical properties with other short end-segment metaphyseal-diaphyseal fractures with regard to the difficulty in obtaining stable fixation. Although predominantly associated with low-energy older age patients, high-energy trauma in young patients can result in similar patterns of fracture. Pertrochanteric femoral fractures are of intense interest globally. They are the mostfrequently operated fracture type, have the highest postoperative fatality rate of surgically treated fractures, and have become a serious health resource issue because of the high cost of care required after injury. The reason for the highcost of care is primarily related to the poor recovery of functional independence after conventional fracture care in many patients. Interestingly there has been no significant improvement in mortality or functional recovery over the past 50 yearsof surgical treatment. Paradoxically the last 50 years of acquiescence to the status quo of hip fracture treatment are

related to false assumptions that have been a hindrance to improvement in the managem ent of the hip fracture patient: (i) uncontrolled shortening and varus collapse are acceptable in hip fractures but not other fractures; (ii) reduction does not matter with sliding screw systems, as the fracture will collapse to stability because rotation is not a problem and placement of the head fixation takes precedence over fracture reduction; (iii) union without implant failure overrides the requirement of a stable anatomic reduction to the detriment of optimal functional recovery; and (iv) the orthopaedic surgeon just fixes the fracture, as opposed to treating the total musculoskeletal needs of the patient. The reasons for these assumptions relate directly to the historical evolution of hip fracture treatment and the arguments that shaped our current understanding. A new paradigm regarding hip fracture care and treatment is currently evolving, which hopefully will advance our treatment goal back to optimal functional recovery and prevention offuture hip fractures. In 1997 Gullberg et al. estimated that the future incidence of hip fracture worldwidewould double to 2.6 million by 2025, and 4.5 million by 2050. 79 The percentage increase will be greater in men (310%) than women (240%). In 1990 26%of all hip fractures occurred in Asia, whereas this figure could rise to 37% in 2025 and 45% in 2050. 143 Hagino et al. reported a lifetime risk of hip fracture for individuals at 50 years of age of 5.6% for men and 20.0% for women. 82 Since 1986 in the Tottori Prefecture, Japan, the acceleration of hip fracture incidence continues for both genders. There is hope that hip fracture risk has begun to decline in certain areas of the world, but the reason is unknown. In

Denmark the incidence of hip fractures has declined about 20% from 1997 to 2006; Nonetheless, this decline cannot be explained by antiosteoporotic medications, whose effect should only be an approximatereduction of 1.3% in men and 3.7% in women. 2 Epidemiologic studies among Olmsted County, Minnesota, residents in 1980 to 2006 revealed that the incidence of a first-ever hip fracture declined by 1.37%/year for women and 0.06%/year for men.The cumulative incidence of a second hip fracture after 10 years was 11% in women and 6% in men. The focus of surgical research regarding internal fixation in the late twentieth century was to minimize implant failure and avoidance of cutout of the femoral head and neck fixation components. Because many ofthese fractures are associated with osteoporosis, the current paradigm shift regarding hip fracture care relates to three main strategies: (i) Prevention by aggressive screening and treatment of patients with high risk for fragility fracture;(ii) standardization of hip fracture centers with aggressive early intervention and protocols to avoid complications; and (iii) optimization of fracture reduction and new designs of implant component fixation in osteoporotic bone with conceptual design changes in fixation stability and augmentation of the bone-implant interface. Ovid: Rockwood And Green's Fractures In Adults chm:///D:/Carti Costik/Rockwood.and.Green' 1 din 73 08.03.2014 22:12