In this study, Between January 2014 and October 2019, 118patients were selected( 51 males and 67 females, aged 37–96 years, with an average age of 76 years). Among them, 71 cases were on the left side and 47 cases on the right. 93 cases were caused by falls, 17 cases caused by traffic accidents, 8 cases caused by cycling injury.
The inclusion criteria were closed intertrochanteric fracture patients who received internal fixation on traction bed, and who could not achieve satisfactory closed reduction through the process of "external rotation, abduction, traction, adduction and internal rotation". Attempted for closed reduction should be made no more than three times by senior attending physicians or professors.
The quality of fracture reduction was determined with the use of intra-operative fluoroscopic images and immediate postoperative radiographs. Evaluation of reduction quality during surgery was important. The distal fragment on the anteroposterior view and the anterior cortex on the lateral view was described in terms of cortical thickness. Fractures were graded as “good,” “acceptable” or “poor” based on three radiographic criteria.
1. Periosteum detacher pressing technique [Fig. 1]
When the medial cortical continuity was lost in anteroposterior view, a periosteum detacher was entered through the proximal intramedullary nail master incision, guided by fluoroscopy, along the trunk Angle and pressed the proximal end of the fracture to recover medial cortical continuity.
After the intramedullary nail was inserted, in anteroposterior view, One fragment displaced outwards was sometimes found and it could be reduced by periosteum detacher. Compared with Kirschner wire or Schneider wire, the cross section of periosteal detacher was relatively large, which avoid the risk of secondary fracture.
2. Caustic forceps clamping technique [Fig. 2]
When we met a sagittally unstable intertrochanteric fracture, the displacement of proximal fragment was significant determined by muscular forces. Gentle traction was applied to make the fractured main fragments to approximately the same level.Caustic forceps through the same incision used for insertion of head and neck screws as a clamping was helpful to achieve temporary anatomical reduction.
3. Reduction of Kirschner pin as a joystick [Fig. 3]
The sagittal displacement was reduced using a Kirschner pin. The tip of the Kirschner pin was placed at the medial cortex of the proximal fragment in the anteroposterior view and at the anterior cortex of the proximal fragment in the lateral view. When an good or acceptable degree of reduction was achieved with the Kirschner pin as a joystick technique, another pin was used to maintain of reduction.
4. Top rod technique [Fig. 4]
The anteroposterior view revealed Good alignment, while the lateral view showed the femoral shaft in front of the head and neck. For the top rod technique, the rod was inserted the anterior cortex of the distal fragment through an incision which was only one centimeter. The rod acted directly on the bone surface applied down vectored force to the malaligned fragment and leaded to fracture reduction.
5. Reduction of thyroid retractor traction [Fig. 5]
For the displacement of the coronal plane, despite a good axial alignment in the lateral view, a small accessory lateral incision, at the level of the lesser trochanter, the proximal fragment could be pulled outward by the thyroid retractor traction to achieve reduction.
6. Cerclage wire binding reduction [Fig. 6]
When the intertrochanteric fracture involvement below lesser trochanter level, anatomical reduction through closed manipulation was of significant difficulty. Via a small lateral incision, a cerclage wire was frequently employed to achieve and maintain satisfactory reduction permanently. Additional banding was taken before intramedullary nailing had been performed. Meanwhile, the cerclage wire could effectively prevented loss of reduction of reaming and insertion of an intramedullary nail.
7. Steinmann pin prying reduction [Fig. 7]
Usually the proximal displacement of the fracture was not obvious. The Steinmann pin inserted along the anterior cortex of the proximal femur through a 2 mm stab wound and the tip was introduced between the proximal and distal fragment. We attempted at levering out the proximal fragment. Reduction was finished by prying the Steinmann pin.