Greater Trochanter Fixation Technique Sees Improved Results with Maximalist ApproachJuly 24, 2023 - Eden McCleskey
Fixation of the greater trochanter (GT) in conjunction with total hip arthroplasty (THA) is a challenging task due to the complex multiplanar forces acting on the proximal femur during daily activities.
Surgeons have employed various methods including wires, cables and cable plate devices, but mixed outcomes and high nonunion rates have resulted in a lack of consensus on the optimal mode of fixation.
In a recent study analyzing the outcomes of 76 cases performed using current-generation cable plate devices, Houston Methodist orthopedic surgeons identified several factors that influence successful union rates and help reduce complications.
"Cable plates are biomechanically the strongest option, but many surgeons don't use them because they think they don't work very well," said Dr. Stephen Incavo, chief of Adult Reconstructive Surgery at Houston Methodist and lead author of the study published in Arthroplasty Today. "We found that they do work, but the best results come from using longer plates and more cables. That makes it a bigger operation, but one that's more likely to be successful."
Dr. Incavo and colleagues analyzed demographic factors, comorbidities, American Society of Anesthesiologists' scores, plate type and plate length of patients treated at Houston Methodist using a traditional posterolateral approach to the hip and femoral shaft. The indications for trochanteric fixation were categorized as periprosthetic fracture, revision THA requiring an extended trochanteric osteotomy, complex primary THA requiring an osteotomy, GT fracture and GT fracture nonunion.
At a mean follow-up period of 29 ± 18 months, the retrospective chart review found a radiographic union rate of 76.3% and a nonunion rate of 23.7%.
Anatomic positioning of the plate (P = .031) and number of cables used (P = .035) were significantly associated with radiographic union. A significant positive correlation was observed between plate length and the number of cables used. The average plate length was 152 ± 44 mm in the union group and 146 ± 36 mm in the nonunion group.
"These results are better than most previously stated outcomes, and with a significantly larger sample size than has ever been recorded," Dr. Incavo stated. "Armed with this knowledge that, in these cases, more is more, we anticipate that outcomes will continue to gradually improve."
Of the nonunion cases, 12 were stable and six were unstable. The reoperation rate for plate-related complications was 36.8%, with 21 patients requiring plate removal due to lateral hip pain and seven requiring repeat fixation for nonunion/hardware failure.
"Fixation of the greater trochanter remains inherently challenging due to poor bone quality and complications related to prior total hip arthroplasty," Dr. Incavo said. "These fractures are definitely difficult to treat, but I think it's important for orthopedic surgeons to know that cable plates can be very effective, and there's still a lot we can do to help these patients who really need help."