Hip fractures are the most severe fracture type in elderly patients with osteoporosis1). Ninety percent of patients with hip fracture are over the age of sixty-five years, and most have major comorbidities that contribute to high rates of morbidity and mortality associated with their hip fractures2). It has been estimated that 250,000 hip fractures occur in the United States every year, with half of them being intertrochanteric3). Primary orthopaedic goals in patients with an intertrochanteric hip fracture are to successfully return to safe mobility-which relies on stability and strength of fracture fixation4).

Over the past fifty years, a wide variety of implants and fixation strategies have been utilized for surgical stabilization of intertrochanteric hip fractures. Antegrade intramedullary nailing of intertrochanteric fractures was introduced by Halder5) in the 1980s in the form of Gamma nail. Since then, a variety of hip fracture fixation devices have been developed for the treatment of intertrochanteric fractures. Additionally, use of a compression hip screw (CHS) is the gold standard treatment for intertrochanteric fractures of the femur⁶7).

For the position of intertrochanteric fracture, traction tables are presently used universally as a standard tool for CHS fixation to achieve and maintain satisfactory reduction before instrumentation is performed. However, a significant amount of time is needed for preoperative set up when a traction table is used. Although there have not been many reports on traction table-associated complications during CHS fixation (e.g., pudendal, sciatic, or femoral nerve injury) due to traction or direct pressure; these complications are also common in patients undergoing femoral nailing because of the large amount of traction force involved^8,910). Furthermore, a traction table may not be available in hospitals with limited resources. Hence, a manual traction technique performed in the supine position using only a radiolucent table has been developed to avoid the need for a traction table. CHS fixation at our institution has been performed since 1979 using traction tables. CHS fixation with patient in lateral decubitus position without using traction table began in 2000 at our institution because of several notable advantages (e.g., easy to prepare for draping, easy to check anteroposterior (AP) and lateral radiograph, and easy to perform surgery, especially when fixing with an additional screw).

The purpose of this study was to introduce a surgical technique of CHS fixation in the decubitus position and report results of 100 consecutive cases.

This retrospective study was approved by the Institutional Review Board (IRB) of Chonnam National University Hospital (CNUHH-2018-046).

Of the included patients, 66 were women and 34 were men (mean age, 77.5 years; range, 45–93 years). Mean bone mineral density values for the spine and femur were −3.0 (range, −6.4–0.6) and −2.7 (range, −5.5–0.4), respectively. Thirty-nine fractures involved the right side and 61 fractures involved the left side. The mean preoperative Koval score was 1.4 (range, 0–5). A total of 70 patients required fixation with an additional screw (n=25), wire (n=12), or screw and wire (n=33). The remaining thirty cases needed no additional fixation. Based on the Evans classification, there were 23 cases of stable fractures and 77 cases of instable fractures. By AO/OTA classification, there were 7 cases of A1.1, 4 cases of A1.2, 1 case of A1.3, 11 cases of A2.1, 40 cases of A2.2, and 37 cases of A2.3 (Table 1).

Mean HHS and Koval scores at the last follow-up (mean 18.3 months after the operation) were 85 months (range, 72–90 months) and 2.6 months (range, 0–5 months; P<0.05) respectively. The mean operation time in the year of 2008, 2009, 2010, or 2011was 94.5, 70.0, 67.6, or 61.7 minutes, respectively. Mean hemoglobin levels were 11.4 g/dL preoperatively and 9.9 g/dL postoperatively.

All patients achieved acceptable reduction of the fracture and desired position of the lag screw. Mean bone union time was 5.0 months (range, 2.0–8.2 months). Radiographic results are as follows: i) AP average tip-apex distance (TAD) (6.95 mm; range, 1.27–14.63 mm), ii) lateral average TAD (7.26 mm; range, 1.20–18.43 mm), and iii) total average TAD (14.21 mm; range, 2.47–28.66 mm). Average angulation was varus 0.72°(range, −7.6°−12.7°). There were no cases of screw tip migration, lag screw cut-out, or nonunion; however, there were four cases of excessive screw sliding and six cases of varus angulation at more than 5°(Table 2). The number of radiologic failures decreased from 5 in 2008 to 1 in 2011 (Fig. 3).

Complications are presented in Table 3 and include delirium (n=16), pneumonia (n=2), pleural effusion (n=2), renal dysfunction (n=2) and one case each of superficial infection and revision surgery to total hip arthroplasty.

Intertrochanteric fractures frequently affect elderly osteoporotic patients, leading to significant morbidity and mortality. With advancing age of the general population, complications during bone healing due to inadequate fixation result in significant consumption of health care system resources15). The major advantage of CHS is that sliding of the lag screw allows impaction of fracture fragments, thereby promoting bone healing. However, its application has limitations¹⁶17). In elderly patients with osteoporotic bone, varus collapse of the proximal fragment and even cut-out of the lag screw may occur due to inadequate screw anchoring in the femoral head. In unstable fractures, excessive sliding of the lag screw caused by insufficient abutment at the fracture may shorten the femur and result in various morbidities.

In a prospective randomized study18) the outcomes of CHS (Osteo Hip Screw; Osteo, Selzach, Switzerland) compared with intramedullary hip screw (IMHS, Smith and Nephew Richards, Memphis, TN, USA.), were similar. The author did not recommend “routine” use of intramedullary hip screws for treatment of intertrochanteric fractures. Baumgaertner et al.19) have performed a prospective randomized study involving 135 patients treated either with a CHS or intramedullary hip screw and observed no differences in rates of functional recovery between the two fixation groups.

There are advantages to treating patients in the lateral position compared with use of a fracture table (e.g., reduced set up time, surgical time, and fluoroscopic exposure time)20). Also, for patients whom fracture table is unavailable, including obese, short stature, or amputated, lateral decubitus position is recommended21).

Data for TAD and cut-out complication were reported in five studies involving femoral intertrochanteric fractures treated with CHS in supine position with a traction table (Table 4). They were compared with this study^22,23,24,2526) and the results were superior for patients with femoral intertrochanteric fractures treated in the lateral decubitus position. Adequate TAD means accurate screw position associated with less cut-out failure25). As it is easy to check accurate screw position in the lateral decubitus position, this study achieved favorable results in TAD and the rate of cut-out failure. However, our study used additional fixation. Further evaluation is needed to evaluate the relationship between additional fixation and cut-out failure.

Limitations of this study included its small sample size, short term follow-up, and its retrospective nature. Another limitation concerns preexisting conditions and postoperative living arrangements that made it difficult for patients to keep follow-up appointments for the twelve-month period of the study, leading to required use of telephone interviews to complete SF-36 and functional recovery score questionnaires.

CHS fixation with patients in the lateral decubitus position provided relatively good results in TAD and cut-out ratio. This approach also significantly reduced preoperative preparation time without sacrificing reduction alignment. This technique is advisable for regular CHS fixation of intertrochanteric fractures, particularly when a traction table is unavailable or when frequent operative bed transfer should be avoided (e.g., polytrauma patients for whom multiple procedures are necessary).