Irreducible Intertrochanteric Fractures: Analysis of Various Fracture Patterns and Reduction Techniques

Background Numerous classifications exist for intertrochanteric (IT) fractures, commonly focused on stability. However, the currently utilized Arbeitsgemeinschaft Osteosynthesefragen and Orthopaedic Trauma Association (AO/OTA) classification has limitations in identifying irreducible fractures. This study aims to answer the following questions: does fracture stability imply irreducibility; which fracture fragments complicate reduction; and which reduction techniques should be employed? Materials and methods Eligibility criteria included fractures in adult long bones without pathological fractures being treated by native conservative means. Preoperative pelvic X-rays were obtained from 49 patients who had intertrochanteric fractures and classified according to the 2018 AO Classification. Anterior-posterior pelvic X-rays were reviewed by six experienced surgeons, who reached a consensus on type, group, and subgroup classifications in this prospective observational study. The methods for intraoperative fracture reduction used by five different unit chiefs were recorded and tabulated. All fractures were reduced on a fracture table with traction and rotation and subsequently checked under C-arm imaging. Persistent non-anatomical alignment with displacement was classified as an irreducible IT fracture. Various reduction techniques, using either semi-open or open methods, were analyzed. Results Fractures classified as AO types A1.1, A1.3, and A2.1 were generally more reducible, while types A2.2, A2.3, A3.1, A3.2, and A3.3 were more frequently irreducible. Patients under 65 years of age were more likely to present with irreducible fracture patterns (P = 0.026), a statistically significant association. A semi-open method using spikes or Hohman's retractors was most commonly employed, with no preliminary cortical fixation using K-wires after reduction. Conclusion Irreducible fractures exhibit unique features on C-arm imaging, potentially leading to increased anxiety and longer operation times. Awareness of these fracture characteristics can assist surgeons in achieving effective reduction and reducing operation time. The 2018 AO classification alone does not reliably predict irreducible IT fractures.