OBJECTIVE: Reverse oblique (RO) and transverse intertrochanteric fracture patterns constitute a challenge for the operating surgeon. Currently, no gold standard fixation method exists. This study aimed to retrospectively compare proximal femoral nail (PFN) to dynamic condylar screw (DCS) plating in the treatment of RO and transverse intertrochanteric fractures.
METHODS: A total of 61 patients fixated by PFN or DCS were included. Of these, 36 were treated with PFN (21 females and 15 males; mean age: 65.52 years), and 25 were treated with DCS (12 females and 13 males; mean age: 59.36 years). The mean follow-up time was 33.8 and 42.6 months (range: 24-108). Radiological evaluation included the quality of fracture reduction, neck-shaft angle change, posteromedial support presence, and bone union time. Complications such as mechanical failure, nonunion, and infection were noted.
RESULTS: The only significant differences between the fixation methods were the superiority of DCS over PFN in earlier fracture union time (mean values: 8.9 versus 14.1 weeks) and the superiority (p=0.007) of PFN in shorter hospital stay (3.4 days versus 5.1 days). No significant difference was observed in radiological parameters. While similar mechanical complication rates were found, a significantly higher nonunion rate was detected with the DCS.
CONCLUSIONS: The most crucial disadvantage of DCS was the high rate of nonunion. Closed fracture reduction in PFN seems to be the most critical parameter to prevent severe complications. The open reduction using DCS showed no advantages over closed reduction and PFN fixation in providing a more anatomical alignment in AO/Orthopaedic Trauma Association (OTA) 31-A3 fractures. However, we recommend PFN application in this type of fracture, since nonunion is more common in DCS.

Reverse oblique peritrochanteric fractures are unstable injuries. They have an inherent tendency of lateral wall opening and varus displacement. Cephalomedullary nails are the preferred implants for fixation of these fractures. Standard techniques and a medial entry point may not always be helpful in correcting alignment, resulting in persisting varus malreduction. A simple technique using a Lowman clamp and a conventional 3.5 mm plate has been described to prevent lateral wall opening and indirectly, the varus malreduction.

BACKGROUND: The reverse oblique trochanteric fractures are common fractures and its treatment poses a challenge. The purpose of this study was to compare the biomechanical parameters of the construct using proximal femoral nail (PFN) and proximal femoral locking compression plates (PFLCP) in these fractures using cadaveric specimens.
METHODS: Twenty freshly harvested cadaveric femoral specimens were randomly assigned to two groups after measuring bone mineral density, ten of which were implanted with PFN and the other ten with PFLCP. The constructs were made unstable to simulate reverse oblique trochanteric fracture (AO type 31A3.3) by removing a standard size posteromedial wedge. These constructs were tested in a computer controlled cyclic compressive loading with 200kg at a frequency of 1 cycle/s (1Hz) and test was observed for 50,000 cycles or until implant failure, whichever occurred earlier. Peak displacements were measured and analysis was done to determine axial stiffness and subsidence in axial loading.
RESULTS: All the specimens in PFN group completed 50,000 cycles and in PFLCP group, seven specimens completed 50,000 cycles. Average subsidence in PFN group was 1.24±0.22mm and in PFLCP group was 1.48±0.38mm. The average stiffness of PFN group (72.6±6.8N/mm) was significantly higher than of PFLCP group (62.4±4.9N/mm) (P=0.04). The average number of cycles sustained by PFLCP was 46634 and for PFN group was 50,000 (P=0.06).
CONCLUSIONS: The PFN is biomechanically superior to PFLCP in terms of axial stiffness, subsidence and number of specimens failed for the fixation of reverse oblique trochanteric fractures of femur.

Reverse oblique intertrochanteric fractures have unique mechanical characteristics and are often treated with intramedullary implants. We compared the outcomes of the reconstruction trochanteric antegrade nail (TAN) with the proximal femoral nail antirotation (PFNA). Between July 2008 and February 2014, we reviewed all patients with reverse oblique intertrochanteric fractures treated at our hospital. Patients with pathological fractures and those who were treated with other than TAN and PFNA nailing systems were excluded. Preoperative assessment included the Abbreviated mental test score (AMT), the ASA grade, pre-injury mobility and place of residence. Postoperative outcome measures included the type of implant used, time to fracture union, failures of fixation and revision surgeries. Fifty-eight patients were included and divided into two groups based on the treatment: 22 patients treated with TAN and 36 patients treated with PFNA systems. The two groups were well matched with regards to demographics and fracture type. The overall union rate was similar in both groups but the time to union was shorter in the TAN group. There were 8 implant failures in the PFNA (22.2%) group compare to none in the TAN group. Implant failure was associated with the severity of fracture (AO 31.A3.3) but was not related to fracture malreduction or screw position (Tip-apex-distance). Our study suggests that the use of reconstruction system with two screws such as TAN may be more suitable implant for reverse oblique intertrochanteric hip fractures.