Proposal of a novel comprehensive classification for femoral intertrochanteric fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 CHANG Shimin ¹ , HU Sunjun ¹ , DU Shouchao ¹ , WANG Zhenhai ² , TIAN Kewei ³ , SUN Guixin ⁴ , WANG Xin ⁵ , RUI Yunfeng ⁶

1. Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090, P. R. China;
2. Department of Traumatic Orthopedic Surgery, Yantaishan Hospital, Yantai Shandong, 264001, P. R. China;
3. No.1 Department of Hip Injury and Disease, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471002, P. R. China;
4. Department of Trauma Surgery, Dongfang Hospital, Tongji University, Shanghai, 200120, P. R. China;
5. Department of Orthopedic Surgery, Tongji Hospital, Tongji University, Shanghai, 200069, P. R. China;
6. Department of Orthopedic Trauma, Zhongda Hospital, Southeast University, Nanjing Jiangsu, 210009, P. R. China;

Corresponding?author：

CHANG Shimin, Email: shiminchang11@aliyun.com

Keywords：

Fracture classification; femoral intertrochanteric fracture; three-dimensional reconstruction; coronal fracture; anteromedial cortex

DOI：

10.7507/1002-1892.202204080

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Objective To introduce a novel comprehensive classification for femoral intertrochanteric fractures, and to accommodate the clinical requirement for the world-wide outbreak of geriatric hip fractures and surgical operations. Methods On the basis of reviewing the history of classification of femoral intertrochanteric fractures and analyzing the advantages and disadvantages of AO/Orthopaedic Trauma Association (AO/OTA) classification in different periods, combined with the current situation of extensive preoperative CT scan and three-dimensional reconstruction and widespread use of intramedullary nail fixation in China, the “Elderly Hip Fracture” Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association proposed a novel comprehensive classification for femoral intertrochanteric fractures, focusing on the structure of fracture stability reconstruction during internal fixation. Results The novel comprehensive classification of femoral intertrochanteric fractures incorporates multiple indicators of fracture classification, including the orientation of the fracture line, the degree of fracture fragmentation, the lesser trochanteric bone fragment and its distal extension length (>2 cm), the posterior coronal bone fragment and its anterior extension width (involving the lateral cortex of the head and neck implant entry point), transverse fracture of the lateral and anterior wall and its relationship with the implant entry point in the head and neck, and whether the cortex of the anteromedial inferior corner can be directly reduced to contact, etc. The femoral intertrochanteric fractures are divided into 4 types (type A1 is simple two-part fractures, type A2 is characterized by lesser trochanter fragment and posterior coronal fractures, type A3 is reverse obliquity and transverse fractures, type A4 is medial comminution which lacks anteromedial cortex transmission of compression force), each of which is subdivided into 4 subtypes and further subdivide into finer subgroups. In a review of 550 trochanteric hip fracture cases by three-dimensional CT, type A1 accounted for 20.0%, type A2 for 62.5%, type A3 for 15.5%, and type A4 for 2.0%, respectively. For subtypes, A2.2 is with a “banana-like” posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior cortical expansion of the posterior coronal fragment to the entry portal of head-neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region. Conclusion The novel comprehensive classification of femoral intertrochanteric fractures can describe the morphological characteristics of fractures in more detail, include more rare and complex types, provide more personalized subtype selection, and adapt to the clinical needs of both fractures and surgeries.

Citation： CHANG Shimin, HU Sunjun, DU Shouchao, WANG Zhenhai, TIAN Kewei, SUN Guixin, WANG Xin, RUI Yunfeng. Proposal of a novel comprehensive classification for femoral intertrochanteric fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(9): 1056-1063. doi: 10.7507/1002-1892.202204080 Copy

1.	張世民. 骨折分類圖表手冊. 北京: 科學出版社, 2014: 1-2.
2.	張世民. 老年髖部轉子間骨折. 北京: 科學出版社, 2019: 136-146.
3.	Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma, 1996, 10(Suppl 1): 1-154.
4.	Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma, 2007, 21(10 Suppl): S1-S133.
5.	Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma, 2018, 32 Suppl 1: S1-S170.
6.	張世民, 余斌. AO/OTA-2018版股骨轉子間骨折分類的解讀與討論. 中華創傷骨科雜志, 2018, 20(7): 583-587.
7.	Hsu CE, Shih CM, Wang CC, et al. Lateral femoral wall thickness. A reliable predictor of post-operative lateral wall fracture in intertrochanteric fractures. Bone Joint J, 2013, 95-B(8): 1134-1138.
8.	衛禛, 張凱, 張世民. 股骨近端外側壁厚度的概念及研究進展. 中國臨床解剖學雜志, 2020, 38(6): 739-742.
9.	Song H, Chen SY, Chang SM. What should be filled in the blank of 31A2.1 in AO/OTA-2018 classification. Injury, 2020, 51(6): 1408-1409.
10.	Song H, Hu SJ, Du SC, et al. Sub-classification of AO/OTA-2018 pertrochanteric fractures is associated with clinical outcomes after fixation of intramedullary nails. Geriatr Orthop Surg Rehabil, 2021, 12: 21514593211056739. doi: 10.1177/21514593211056739.
11.	Rehme J, Woltmann A, Brand A, et al. Does auxiliary cerclage wiring provide intrinsic stability in cephalomedullary nailing of trochanteric and subtrochanteric fractures? Int Orthop, 2021, 45(5): 1329-1336.
12.	Lee WC, Chou SM, Tan CW, et al. Intertrochanteric fracture with distal extension: When is the short proximal femoral nail antirotation too short? Injury, 2021, 52(4): 926-932.
13.	Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
14.	張世民, 胡孫君, 杜守超, 等. 股骨轉子間骨折的穩定性重建概念演化與研究進展. 中國修復重建外科雜志, 2019, 33(10): 1203-1209.
15.	米滿, 張世民. 髖部隱匿性骨折. 中國矯形外科雜志, 2017, 25(8): 720-724.
16.	胡孫君, 杜守超, 熊文峰, 等. 股骨近端防旋髓內釘內固定治療高位股骨轉子間骨折. 中國修復重建外科雜志, 2021, 35(3): 307-311.
17.	張世民, 胡孫君, 杜守超, 等. 小轉子二分型的難復位股骨轉子間骨折手術技巧及療效分析. 同濟大學學報 (醫學版), 2020, 41(6): 772-778.
18.	張英琪, 張世民, 熊文峰, 等. 股骨近端外側壁的骨折特征地圖研究. 中國臨床解剖學雜志, 2017, 35(2): 121-125.
19.	Zhang Y, Sun Y, Liao S, et al. Three-dimensional mapping of medial wall in unstable pertrochanteric fractures. Biomed Res Int, 2020, 2020: 8428407. doi: 10.1155/2020/8428407.
20.	Li J, Tang S, Zhang H, et al. Clustering of morphological fracture lines for identifying intertrochanteric fracture classification with Hausdorff distance-based K-means approach. Injury, 2019, 50(4): 939-949.
21.	Yin B, He Y, Wang D, et al. Classification of femur trochanteric fracture: Evaluating the reliability of Tang classification. Injury, 2021, 52(6): 1500-1505.
22.	Cho JW, Kent WT, Yoon YC, et al. Fracture morphology of AO/OTA 31-A trochanteric fractures: A 3D CT study with an emphasis on coronal fragments. Injury, 2017, 48(2): 277-284.
23.	Kim YV, Lee KH, Lee HH, et al. Impact of coronal plane fragments and anterior big neck fragments on the occurrence of perioperative lateral wall fractures in AO/OTA 31-A1, 2 intertrochanteric fractures treated with cephalomedullary nailing. Eur J Trauma Emerg Surg, 2022. doi: 10.1007/s00068-022-01942-x.
24.	Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric femur fracture treatment in Asia: What we kow and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
25.	Song H, Chang SM, Hu SJ, et al. Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study. J Orthop Surg Res, 2022, 17(1): 27. doi: 10.1186/s13018-022-02921-z.
26.	張世民, 王振海, 田可為. 同時累及同側股骨頸與轉子間兩個解剖區域的骨折類型與研究進展. 中國修復重建外科雜志, 2021, 35(9): 1079-1085.

1. 張世民. 骨折分類圖表手冊. 北京: 科學出版社, 2014: 1-2.
2. 張世民. 老年髖部轉子間骨折. 北京: 科學出版社, 2019: 136-146.
3. Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma, 1996, 10(Suppl 1): 1-154.
4. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma, 2007, 21(10 Suppl): S1-S133.
5. Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma, 2018, 32 Suppl 1: S1-S170.
6. 張世民, 余斌. AO/OTA-2018版股骨轉子間骨折分類的解讀與討論. 中華創傷骨科雜志, 2018, 20(7): 583-587.
7. Hsu CE, Shih CM, Wang CC, et al. Lateral femoral wall thickness. A reliable predictor of post-operative lateral wall fracture in intertrochanteric fractures. Bone Joint J, 2013, 95-B(8): 1134-1138.
8. 衛禛, 張凱, 張世民. 股骨近端外側壁厚度的概念及研究進展. 中國臨床解剖學雜志, 2020, 38(6): 739-742.
9. Song H, Chen SY, Chang SM. What should be filled in the blank of 31A2.1 in AO/OTA-2018 classification. Injury, 2020, 51(6): 1408-1409.
10. Song H, Hu SJ, Du SC, et al. Sub-classification of AO/OTA-2018 pertrochanteric fractures is associated with clinical outcomes after fixation of intramedullary nails. Geriatr Orthop Surg Rehabil, 2021, 12: 21514593211056739. doi: 10.1177/21514593211056739.
11. Rehme J, Woltmann A, Brand A, et al. Does auxiliary cerclage wiring provide intrinsic stability in cephalomedullary nailing of trochanteric and subtrochanteric fractures? Int Orthop, 2021, 45(5): 1329-1336.
12. Lee WC, Chou SM, Tan CW, et al. Intertrochanteric fracture with distal extension: When is the short proximal femoral nail antirotation too short? Injury, 2021, 52(4): 926-932.
13. Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
14. 張世民, 胡孫君, 杜守超, 等. 股骨轉子間骨折的穩定性重建概念演化與研究進展. 中國修復重建外科雜志, 2019, 33(10): 1203-1209.
15. 米滿, 張世民. 髖部隱匿性骨折. 中國矯形外科雜志, 2017, 25(8): 720-724.
16. 胡孫君, 杜守超, 熊文峰, 等. 股骨近端防旋髓內釘內固定治療高位股骨轉子間骨折. 中國修復重建外科雜志, 2021, 35(3): 307-311.
17. 張世民, 胡孫君, 杜守超, 等. 小轉子二分型的難復位股骨轉子間骨折手術技巧及療效分析. 同濟大學學報 (醫學版), 2020, 41(6): 772-778.
18. 張英琪, 張世民, 熊文峰, 等. 股骨近端外側壁的骨折特征地圖研究. 中國臨床解剖學雜志, 2017, 35(2): 121-125.
19. Zhang Y, Sun Y, Liao S, et al. Three-dimensional mapping of medial wall in unstable pertrochanteric fractures. Biomed Res Int, 2020, 2020: 8428407. doi: 10.1155/2020/8428407.
20. Li J, Tang S, Zhang H, et al. Clustering of morphological fracture lines for identifying intertrochanteric fracture classification with Hausdorff distance-based K-means approach. Injury, 2019, 50(4): 939-949.
21. Yin B, He Y, Wang D, et al. Classification of femur trochanteric fracture: Evaluating the reliability of Tang classification. Injury, 2021, 52(6): 1500-1505.
22. Cho JW, Kent WT, Yoon YC, et al. Fracture morphology of AO/OTA 31-A trochanteric fractures: A 3D CT study with an emphasis on coronal fragments. Injury, 2017, 48(2): 277-284.
23. Kim YV, Lee KH, Lee HH, et al. Impact of coronal plane fragments and anterior big neck fragments on the occurrence of perioperative lateral wall fractures in AO/OTA 31-A1, 2 intertrochanteric fractures treated with cephalomedullary nailing. Eur J Trauma Emerg Surg, 2022. doi: 10.1007/s00068-022-01942-x.
24. Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric femur fracture treatment in Asia: What we kow and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
25. Song H, Chang SM, Hu SJ, et al. Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study. J Orthop Surg Res, 2022, 17(1): 27. doi: 10.1186/s13018-022-02921-z.
26. 張世民, 王振海, 田可為. 同時累及同側股骨頸與轉子間兩個解剖區域的骨折類型與研究進展. 中國修復重建外科雜志, 2021, 35(9): 1079-1085.

Chinese Journal of Reparative and Reconstructive Surgery

Proposal of a novel comprehensive classification for femoral intertrochanteric fractures

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