Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures--a review.

Intramedullary nailing is gradually emerging as the treatment of choice for pertrochanteric femoral fractures. Nevertheless, prospective randomised trials have failed to demonstrate the assumed superiority of cephalomedullary nails over the traditional treatment with the sliding hip screw. On the contrary, the gamma nail has been implicated in predisposing to secondary femoral fractures, although this seems to be rectified by newer techniques and nail designs. Sliding hip screw fixation remains the gold standard but can lead certain unstable pertrochanteric fracture subgroups to failure. Amongst these are transverse or reverse obliquity but also multifragmentary fractures, that suffer intra- or postoperative shattering of the lateral trochanteric wall. Nails seem to prevent failure by opposing the uncontrollable medialisation, and eventual failure, that occurs under these circumstances. The importance of the size of the proximal fracture fragment has not yet been elucidated. Nail fixation is, thus, mandatory in a small percentage of grossly unstable fractures, whose characteristics are still undergoing definition.