Trochanteric buttress plate augmentation

Lateral wall fractures managed with trochanteric buttress plating. How effective are these TBP ?

1. © 2023 Journal of Telangana Orthopaedic Surgeons Association | Published by Wolters Kluwer - Medknow 15
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Abstract
Original Article
IntroductIon
Pertrochanteric fractures of hip are common geriatric fractures
posing challenges in management, particularly in unstable
fracture patterns. Fracture collapse is one of the common
complications that lead to poor outcome or reoperation most
of the times. Successful outcome of unstable intertrochanteric
fractures depends on the integrity of posteromedial cortex in
unstable fractures
[1]
and lateral wall thickness.
[2]
Even if the
lateral wall is intact prior to surgery, its iatrogenic fracture
by the hardware chosen decides collapse of ?xation. Hence,
careful evaluation of a preoperative radiograph with respect to
lateral wall integrity is crucial in deciding hardware of choice.
Lateral wall thickness of the greater trochanter plays an
important factor in classifying pertrochanteric fractures
into A1 and A2 subtypes when using AO classification
system.
[3]
Multifragmentary pertrochanteric fractures with an
incompetent lateral wall are termed the 31A2 subtype.
[3]
The
lateral wall thickness is the distance from a reference point
3 cm below the innominate tubercle of the greater trochanter
angled about 135° upward toward the fracture line in the
anteroposterior (AP) X-ray view
[4]
[Figure 1]. The lateral wall
thickness must be <20.5 mm for the fracture to be called as A2
subtype. Since the hardware of choice used to treat depends
on lateral wall integrity, it is recommended to keep all the
options of implants from intramedullary devices to sliding hip
screws and trochanteric stabilization systems ready for surgery.
Background: Per-trochanteric fractures of hip are common geriatric fractures posing challenges in management, particularly in unstable fracture
patterns. Successful outcome of unstable intertrochanteric fractures depends on integrity of posteromedial cortex in unstable fractures and
lateral wall thickness. Materials and Methods: In this study we reviewed the outcome of lateral wall augmentation by trochanteric buttress
plate (TBP) supplemented to proximal femoral nailing in patients with incompetent lateral wall of per-trochanteric fractures. Results: A total
of 24 patients who underwent Proximal femoral nail (PFN) ?xation and trochanteric augmentation by TBP were included in the study, of which
3 patients did not follow up for six months and hence excluded. Mean lateral wall thickness in the study group was 12.2 mm (7.1-18.1mm).
Of the 21 patients, 17 patients had pre operative lateral wall fracture and 04 patients had iatrogenic lateral wall fracture while drilling. Mean
lateral wall width in these 4 cases is about 9.4mm (6-11mm). None of the patients in the study group had varus ?xation of fracture. Average
time to union was 12.6 weeks (10-16 weeks). Conclusion: The thickness of the femoral lateral wall should be assessed prior to surgery by
a proper traction view or a CT scan and TBP augmentation be considered when selecting a suitable ?xation implant for AO 31A2 unstable
intertrochanteric fractures with or without lateral wall fracture patterns.
Keywords: Intertrochanteric fracture, lateral trochanteric wall, proximal femoral nail, trochanteric buttress plate
Address for correspondence: Dr. Ranjith Kumar Yalamanchili,
Department of Orthopaedics, All India Institute of Medical Sciences,
Bibinagar, Hyderabad, Telangana, India.
E-mail: [email protected]
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How to cite this article: Ravindranath VS, Yalamanchili RK, Palla SR,
Baddula AR, Mudavath S, Vuthpala VM. Trochanteric buttress plate
augmentation – Is the buttressed lateral wall integrity an euective way for
good outcome of pertrochanteric fractures treated by proximal femoral nail?
J Telangana Orthop Surg Assoc 2023;XX:XX-XX.
Trochanteric Buttress Plate Augmentation – Is the Buttressed
Lateral Wall Integrity an Effective Way for Good Outcome of
Pertrochanteric Fractures Treated by Proximal Femoral Nail?
V. S. Ravindranath
1
, Ranjith Kumar Yalamanchili
2
, Sukarna Reddy Palla
1
, Anand Reddy Baddula
1
, Shashivardhan Mudavath
1
, Venu Madhav Vuthpala
1
1
Department of Orthopaedics, ESIC Medical College, Hyderabad, Telangana, India,
2
Department of Orthopaedics, All India Institute of Medical Sciences, Hyderabad,
Telangana, India
AQ1
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***
DOI:
10.4103/JTOSA.JTOSA_7_23
Submitted: 06-Sep-2023 Revised: 20-Sep-2023
Accepted: 20-Sep-2023 Published: ***

2. Journal of Telangana Orthopaedic Surgeons Association ¦ Vo l u m e 1 ¦ Issue 1 ¦ January-April 202316
Figure 1: The lateral wall thickness is the distance from a reference point
3 cm below the innominate tubercle of the greater trochanter angled about
135° upward toward the fracture line
Figure 2: Proximal femoral nail with trochanteric buttress plate. Heads of
proximal screws buttress the lateral wall against the plate
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Ravindranath, et al.: Trochanteric buttress plate augmentation for lateral wall integrity
However, in cases where iatrogenic lateral wall fracture occurs,
utilization of these trochanteric buttress plates (TBPs) helps to
prevent collapse.
[5]
Biomechanically, trochanteric stabilization
by lateral wall augmentation while using a sliding hip device
prevents medialization and collapse.
[6]
There are reports in the
literature where an intramedullary device yields comparable
results to dynamic hip screw (DHS) and stabilization plate in
treating unstable pertrochanteric fractures.
[7,8]
In this study,
we reviewed the outcome of the lateral wall augmentation
by TBP supplemented to proximal femoral nailing in patients
with incompetent lateral walls of pertrochanteric fractures.
Methodology
The medical records of patients with pertrochanteric
fractures of subtype AO 31-A2 with fracture of the lateral
wall, operated at our institute with trochanteric stabilization
plate augmentation from September 2020 to March 2023,
were reviewed retrospectively. The patients who underwent
reoperations primarily during the study period and those
with <6-month follow-up are excluded from the study. A total
of 24 patients who underwent trochanteric augmentation by
TBP were included in the study, of which three patients did
not follow-up for 6 months and hence were excluded from
the study. The mean age of the study group was 62 years
(range 57–82 years), with 14 males and seven females. The
average delay to surgery was 3.8 days (range 1–13 days),
which was mostly related to the optimization of comorbidities
for anesthesia. After regional anesthesia, patients were
operated under ?uoroscopic guidance on the traction table.
Four patients had intact lateral wall with AO 31-A2 fracture
patterns in preoperative evaluation by plain AP X-ray views,
which, upon intraoperative traction view ?uoroscopy, revealed
lateral wall fracture and hence needed augmentation by
trochanteric buttress plating. All the patients included in the
study had a history of domestic falls from standing height as
the cause of fracture. The proximal femoral nail (PFN) with a
6° mediolateral bend (nail length: 250 mm having a proximal
diameter of 15 mm, with 8 mm compression, and 6.4 mm
derotation screw) was used along with a TBP of two-holed
with the provision of locking screws distally in femur beneath
the compression screw slot [Figure 2]. After satisfactory
reduction of the medial cortex, two 3.0 k wires are ?xed from
the posterior and anterior parts of the greater trochanter to
the femoral head, ensuring enough space for the nail to pass
through. Implantation of PFN is done, and an incision is given
over the lateral aspect of the femur to accommodate the TBP
and buttress the lateral wall by screw heads of the 8.0 mm
and 6.4 mm screws of PFN through the plate. Unicortical
locking in TBP is done for additional stability based on the
fracture pattern in the greater trochanter and shaft of the
femur beneath the PFN screw position [Figure 3]. None of
the cases needed additional stabilization using cerclage wires.
Postoperatively, patients were encouraged in bed sitting and
knee range of motion exercises as tolerated and mobilization
with walker after 4 weeks of surgery. Patients were followed
up radiologically for union/nonunion and complications with
respect to screw cut through or back out or fracture collapse.
results
The average follow-up period of the study group was
7.8 months, with the exclusion of three patients who did
not complete 6 months of follow-up. The mean lateral wall
thickness in the study group was 12.2 mm (7.1–18.1 mm). Of
the 21 patients, 17 patients had preoperative lateral wall fracture
and four patients had iatrogenic lateral wall fracture while
drilling. The mean lateral wall width in these four cases is about
9.4 mm (6–11 mm). None of the patients in the study group
had varus ?xation of fracture. The average time to union was
12.6 weeks (10–16 weeks). The mean duration of surgery was
89 min (range: 73–132 min) and the average intraoperative blood
loss was 183 ml (150–560 ml). Six patients (28.5%) required
postoperative blood transfusion within 24 h. Seven patients
developed local complications, namely, “Z” euect (n = 2) and

3. Journal of Telangana Orthopaedic Surgeons Association ¦ Vo l u m e 1 ¦ Issue 1 ¦ January-April 2023 17
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Ravindranath, et al.: Trochanteric buttress plate augmentation for lateral wall integrity
lateral migration of neck screws (n = 5) [Table 1]. Among
the ?ve patients who developed lateral migration, one patient
required the removal of screws after fracture union due to
painful impingement of screws [Figure 4]. None of the patients
in the study group had any complications like super?cial or
deep infections and hardware failure requiring revision surgery.
dIscussIon
Biomechanical advantages of treatment of unstable
intertrochanteric fractures by intra-medullary devices like
PFN have been well documented in the literature.
[9]
PFN is
advantageous for its load-bearing ability, shorter bending
momentum that allows reasonably early weight-bearing for
patients. The integrity of the lateral wall is being widely
recognized in as a predictor of failure following the treatment
of pertrochanteric fractures. From the clinical perspective, if
the integrity of the lateral wall is intact and suvciently wide
(more than 20.5 mm), the chances of iatrogenic fracture while
drilling are less and such fractures can be proceeded with either
DHS or a PFN. Joshi et al. reported in their series that 1.7% of
the patients with an A1 fracture pattern had iatrogenic lateral
wall fracture, as compared to 50% of patients with type A2.2
and type A2.3 sustained an iatrogenic lateral wall fracture
while using DHS as hardware in ?xing them.
[10]
In cases
where the lateral wall is thin and vulnerable, intramedullary
devices like PFN are of choice with or without augmentation
by TBP. Poor bone quality in the form of osteoporosis can lead
to iatrogenic comminution of the lateral wall while inserting
the hardware. In our series, we have observed four patients
who sustained iatrogenic lateral wall fractures while using
drilling for proximal screws of PFN; however, quanti?cation of
osteoporosis in those patients is not done. Kim et al. reported
that the displaced lateral femoral wall reduces spontaneously
due to dynamic collapse in the postoperative period but failed
to explain the same in four of the 25 cases reported.
[11]
In our series, among the 31A2 subgroup, four patients (19%)
whose preoperative X-rays did not show any lateral wall
fracture, upon ?uoroscopic view on traction, showed lateral
wall fracture. Hecht et al., in their series, observed that 22%
of pertrochanteric fractures which were classi?ed initially as
AO 31A1 based on plain radiographs, were reclassi?ed as AO
31A2 unstable fractures upon computed tomography (CT) scan
review.
[12]
This reiterates the increased accuracy of CT scan
in detecting the integrity of lateral wall preoperatively. The
lateral wall fractures on axial cuts of CT scans show that the
lateral wall cortex of the femur is not simply a wall but rather
the portion of the cylindrical femoral shaft that is divided
from the head-and-neck segment by the main fracture plane.
When the lateral wall has an additional coronal plane fracture
separating the posterior portion of the trochanter from the
anterolateral cortex, the lateral cortex becomes much smaller
despite a lateral wall thickness measurement on X-ray that
would classify the injury as AO 31A1 (stable con?guration)
[12]

[Figure 5]. We recommend intraoperative ?uoroscopy on
Figure 3: (a) Preoperative radiographs anteroposterior, lateral, and traction view showing lateral wall fracture. (b) Intraoperative radiographs showing
reduction of lateral wall with trochanteric buttress plate after inserting proximal femoral nail proximal screws
ba
Figure 4: Lateral collapse of screws seen in two cases. (a) Severe lateral displacement of screws is seen in the osteoporotic femoral head, which
finally healed by collapse. (b) Lateral collapse of screws seen is due to fracture site compression
ba

4. Journal of Telangana Orthopaedic Surgeons Association ¦ Vo l u m e 1 ¦ Issue 1 ¦ January-April 202318
traction table or CT scan in labeling AO 31A1 and AO 31A2
fractures precisely.
When time taken for surgery augmented with TBP could not be
compared as there will be a lot of heterogenicity with respect to
fracture extension con?gurations. Similarly, blood loss during
this additional augmentation cannot be compared to routine
intramedullary ?xation alone. None of the patients in our study
group had varus ?xation and posteromedial cortex continuity
are restored on initial ?xation. However, the two cases of the
z euect observed must have been due to the presence of lateral
wall fracture causing weak hold laterally and screws in the
femoral head not getting enough purchase due to osteoporosis.
In ?ve patients of our series, lateral displacement of screws
noted was mostly due to shearing forces caused by the tendency
for lateral displacement of the proximal end and medial
displacement of the distal end in unstable A2 fractures. Gupta
et al. reported a mean sliding of 3.4 mm in unstable fractures
treated by DHS with trochanteric stabilization plates.
[5]
In our
series, complications are fewer when compared to the technical
and mechanical complications described in the literature.
[13,14]
The loss of the integrity of the lateral wall may lead to
excessive collapse, varus malreduction, medialization of
the shaft, shortening, instability, increased reoperation rates,
and converting stable IT fracture into a reverse oblique
pattern.
[15]
Many ways to augment lateral wall such as TBP,
[7]

cerclage wires,
[16]
and percutaneous buttress screw
[17]
are
used. Gadegone et al. presented a series of 82 patients with
augmentation of the lateral wall by the additional percutaneous
screw to stabilize the lateral wall fracture fragment.
[17]
Healing
time and collapse were similar to PFN augmented with the
TBP group and it had the advantages of less blood loss and less
operating time compared to augmentation with TBP over PFN.
However, the authors feel from their experience, that TBP is
advantageous compared to percutaneous buttress screw, which
has high learning curve due to the need of understanding the
fracture orientation approach for percutaneous insertion and
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Ravindranath, et al.: Trochanteric buttress plate augmentation for lateral wall integrity
Table 1: Relation of fracture configuration and
complications in the study group
Fracture pattern AO 31-A2
fixed by PFN and TBP
Number of
patients
Complication
Lateral wall fracture with GT
communication
9 Z euect - 1
Lateral migration
of neck screws - 3
Lateral wall iatrogenic fracture4 Lateral migration
of neck screws - 1
Z euect - 1
Lateral wall without
signi?cant GT communication
8 Lateral migration
of neck screws - 1
PFN: Proximal femoral nail, TBP: Trochanteric buttress plate, GT: Greater
trochanter
Figure 5: (a) Preoperative X-ray showing unstable pertrochanteric fracture with lateral wall involvement. (b) Intraoperative lateral view showing extension
of the lateral wall to the posterior part of greater trochanter. (c) Reaming displacing the lateral wall. (d) Lateral wall fragment and posterior extension
to greater trochanter stabilized by a trochanteric buttress plate and screws
dc
ba

5. Journal of Telangana Orthopaedic Surgeons Association ¦ Vo l u m e 1 ¦ Issue 1 ¦ January-April 2023 19
cerclage wiring that has potential chances of unwanted soft
tissue stripping on the medial side including cutting through
into the fractured area. Added to above, TBP has the advantage
of no prominence of hardware as the PFN screws ?ush to the
TBP Plate buttressing against it compared to cerclage wires
that can irritate lateral soft tissue.
Disadvantages of TBP augmentation are increased operating
time, incision exposure, blood loss, and radiation exposure. The
key surgical steps for favorable results include prior fracture
reduction to nail insertion, and the use of correct proximal
screw sizes of PFN to achieve the desired buttressing euect on
the broken lateral wall. We feel contemplating long-term results
and comparing them with other hardware groups in similar
patterns along with a bigger sample size will strengthen the
evidence of augmentation of TBP in thin lateral wall fractures.
It is recommended to always arrange for TBP in the implant
armamentarium while performing proximal femoral nailing, as
it can help ?x the iatrogenic broken lateral trochanteric wall.
conclusIon
The lateral wall integrity is a key predictor to prevent excessive
collapse or varus collapse and for good outcomes following
?xation. The thickness of the femoral lateral wall should be
assessed before surgery by a proper traction view or a CT scan
and TBP augmentation be considered when selecting a suitable
fixation implant for AO 31A2 unstable intertrochanteric
fractures with or without lateral wall fracture patterns.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no con?icts of interest.
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Ravindranath, et al.: Trochanteric buttress plate augmentation for lateral wall integrity