TREATMENT

OF

A COMPARISON

OF
G.

THE

INTERTROCHANTERIC
FEMUR
RICHARDS

H. HEYSE-MOORE,

From

The

SCREW-PLATE
A. G. MAcEACHERN,

Princess

Elizabeth

Orthopaedic

FRACTURES

WITH

THE

D. C. JAMESON

Hospital,

OF

JEWETT

THE

NAIL-PLATE

EVANS

Exeter

One hundred and seven patients with intertrochanteric

fractures
of the femur freated with a Richards
screw-plate
were compared
refrospectively
with 103 patients treated with a Jewett nail-plate.
The mortality
and morbidity
were similar in the two groups.
In patients with comparable
fractures,
those treated with a
Richards
device mobilised
more quickly and left hospital sooner, and more of them returned to their homes.
Failures
of stabilisation,
both clinically
and radiographically,
were fewer in this group. The reliability
of
fixation with a correctly
positioned
Richards
screw-plate
couldjustlfy
the omission of outpatient
follow-up in
all but a small group ofpatients
with severe unstable fractures or grossly defective bone stock. The higher cost
of a Richards
Implant and the slightly longer operative
procedure
were outweighed
by savings in occupancy
of acute and long-stay
hospital
beds.
Hip fractures
present
an increasing
demand
on orthopaedic trauma
departments
and long-stay
hospital
facilities in this country.
Their number
has risen in England
and Wales from I 5 000 in 1959 to 40 000 in 1979 (Fenton
Lewis 1981).
Although
intertrochanteric
fractures
heal well with
conservative
inpatient
treatment
(Murray
1949) there is
a strong argument
for early mobilisation
ofthese
patients
by means of adequate
stabilisation
of the fracture
using
internal
fixation.
This has been the aim of treatment
in
Exeter
since the introduction
of the stainless
steel onepiece angled V-nail-plate
by Capener(Capener
1944) and
the subsequent
adoption
of the Jewett nail-plate
(Jewett
1941) in the mid-seventies.
In common
with other devices
(OBrien,
Shy and Bubis 1946; Cleveland,
Bosworth
and
Thompson
1947 ; Dimon
and Hughston
1967 ; Wynn
Jones et a!. 1977), three problems
were still frequently
encountered
: failure of fixation
often requiring
re-operation ; inadequate
stabilisation
delaying
mobilisation
and
discharge
from hospital;
and uncertain
fixation requiring
prolonged
outpatient
follow-up
(Figs 1 to 4).
The Richards
screw-plate
was adopted
in 1979 after
encouraging
early reports
(Ecker,
Joyce and Kohl 1975;
Jensen,
T#{248}ndevold and Mossing
1978). It is a stainless
steel fixed-angle
two-piece
device
with a sliding
intramedullary
lag-screw
and a choice
of plate
lengths
G. H. Heyse-Moore,
FRCS, Orthopaedic
Senior
Registrar
A. G. MacEachern,
FRCS,
Orthopaedic
Senior
Registrar
D. C. Jameson
Evans, FRCS, Consultant
Orthopaedic
Surgeon
Princess
Elizabeth
Orthopaedic
Hospital,
Wonford
Road, Exeter
4UE, England.
Requests
for reprints
should be sent to Mr D. C. Jameson
Evans.

1983 British

Editorial
0301 -620X/83/3066-0262

262

Society
$2.00

of Bone and Joint

Surgery

EX2

designed
to resist
angular
deformation
but permit
shortening
in the axis of the screw with a facility
of
initial
compression.
The operative
technique
is fully
described
by Ecker et a!. (1975).
A random prospective
trial of the two implants
was
originally
planned.
However,
it soon became
apparent
that the results using the Richards
device were superior.
The trial was therefore
abandoned
and this paper reports
the results ofa series ofintertrochanteric
fractures
treated
with the Richards
screw-plate
compared
with a preceding
series treated
with the Jewett
nail-plate.
MATERIAL

AND

METHODS

Three hundred
and seventeen
patients
with intertrochanteric
fractures
of the femur were treated
in Exeter during a two-year
period between
1979 and 1981. One hundred
and seven had died or been lost to followup. The remaining
210 were followed
until union of the fracture
or
failure of fixation : 103 with the Jewett nail-plates
and 107 with the
Richards
screw-plates.
This represented
a 66 per cent follow-up
rate in
both groups.
No two groups of patients
are identical
but the discernible
factors
which might bias comparison
were assessed : sex and age distribution,
previous
mobility and independence,
quality of bone stock, and type of
fracture.
Women
formed
74 per cent of the group treated
with the
Jewett nail-plates
and 83 per cent ofthe group treated with the Richards
screw-plates.
Ages ranged from 54 to 99 years in the former group and
from 41 to 95 years in the latter group, with a mean age of 79 in both
groups.
There
was little difference
between
the two groups
in the
proportion
of those previously
disabled,
living in sheltered
accommodation or needing
nursing
care. The group treated with the Richards
screw-plates
had a slightly higher proportion
ofpatients
with markedly
deficient
bone as estimated
on admission
radiographs
by one observer
(48 per cent as compared
with 33 per cent in the other group); and of
patients
with a serum alkaline
phosphatase
greater than 100 international units per litre on admission
(65 per cent as compared
with 52 per
cent in the othergroup).
Clearly this does not indicate the true incidence
ofosteoporosis
or osteomalacia
but it shows that the superior
results in
the group treated
with the Richards
screw-plates
are not due to these
THE JOURNAL

OF BONE AND JOINT SURGERY

TREATMENT

Fig.

Failure

patients

stronger

modification

Stable

treated

nail-plate.

bone.
of

fractures

group

the

Figures

The

the

(Jensen

with

table
No

reduction

1 and

through
Formal

was

made

fragments

The reduced
Anatomical

reduction

not

in the

related

carried
on

and

5).

cent

to have
with

group

treated

of the

of stabilisation,

demonstrated

per cent of the anatomically

plates but in none of those

in

out

after

an initially

undisplaced

4
fracture.

STABLE

initial
traction

muscle.
persisted.
the

of

achieved

2-fragmentary

reduction.

in 68 per cent

nail-plates

the

and

Richards

displaced

undisplaced

with the Richards

quality

Jewett
with

Fig.
4-In

group

or to displace

treated

been

the

3 and

1967).

differences

treated

in the

position

Figures

of the

cent

a Charnley

Hughston

in the group
to

appeared

group

of fractures

Failure

were
control

a valgus

(Dimon

rate of failure

was

fractures

to obtain

medially

screw-plate

cent

the

a lateral
incision
elevating
the vastus
lateralis
open
reduction
was only done ifgross
deformity

attempt

distal

x-ray

using

1981 ; Fig.
46 per

33 per

fracture.

263

FEMUR

OF THE

Fig.
an unstable

classified

(Jensen

and

FRACTURES

2
2-In

2) formed

nail-plates

under

were

method

Groups

Jewett

1 and

fractures

Evans

treated with the Richards

screw-plates.
Operative
technique.
All operations
manipulative

INTERTROCHANTERIC

Fig.

of a Jewett

having

Jensen

OF

fracture

2-fragmentary

fracture

of

38 per

UNSTABLE

screw-plates.

radiographically,

occurred

in 44

reduced
fractures
with the Jewett
nailanatomically
reduced
with the Richards

screw-plates.
Avoidance

the

ofanterior

femoral

always

head

achieved

cent

fractures,

with

plate

were

screw-plate

unstable

the

allows

unstable

and

demonstrated

incorrectly

Richards

cortical

(Mulholland

radiographically
inserted

or superior

without

nail

was

sought

Gunn

as follows
34 per

22 per cent

with

nail-plate.

for some

ofthe

failures

and

Jewett

placement

penetration

with

the

fractures

in screw

The different
in

operations

rates of failure
the

with

Richards

placement

the

seniority
Jewett

screw-plates

of

surgeon.

nail-plates

were

Richards

screw-plate

were

variations

in operating

time

difficulties
fractures

VOL.

with

the
for

and

92 per

Richards

in both

in the two groups

the

3-fragmentary

fracture

without

posterolateral

support

screw-

stable

and

carried

and
out

of reduction
and
of similar
difficulty
minutes

longer

manoeuvres

65-B,

No.

3. MAY

than
necessary.

1983

found
with

41 percent

Jewett

ofthose

few

device

most

were

of
device

of

with

the

and

44 per cent

operations

by

with
surgeons

largely

to

cent

surgeons

failures

devices

the placement
the Richards
the

per

by consultant

difficult
both

were not related

Forty-six

those cases considered

to be radiographical
been carried out by consultants.
As with any new technique
the first

surgical

the

were

nail-plate:

screw-plate
that

of

that
none

Jewett

Richards

in

not

percentages

implants

the

be seen

but

fractures.

differences

seven

The

those

: for stable
cent

It can

latitude

1972).
in

or screw

of

the
but

related

to

the guide
wire.
took an average

In
of

because

of

the

977

had

extra

3-fragmentary

fracture

without

support

medial

4-fragmentary

Fig.
Jensen
(1981)
(reproduced

modification
from
Acta
permission

fracture

ofthe
Evans
Ortliop
Scand
of the editor

grading
ofiracture
I 98 1 , Suppl
1 f8.
and author).

stability
with
kind

264

G.
The

was

compression

found

that

if maximal
Unlike
the
into

in place

from

Graham

screw
the

barrel

head

used

-thus

is necessary.
it was

out

protrude

was

one
due

engaged

A. G.
in most

cases.

beneath

the

occurred

we do not
The

series
not

taken

screw

(1980)

in our

but

it could

of the sliding

and

compression
the

was

left

impaction

Cameron

screw

screw

1 it was

H. HEYSE-MOORE,

feel

case

(Figs
that

in the

6 and

I. Early

Table

EVANS

postoperative

mortality

in the

original

3 1 7 patients

7).
of

Causes

Jewett
nail-plate
(per cent)

of death

Richards
screw-plate
(per cent)

of the

inserted

barrel

It

D. C. JAMESON

skin

retention

of dislocation

to a screw

MAcEACHERN,

too

to the

far

correct

Pneumonia
Cardiac

10

failure

depth.
Pulmonary

embolus

Stroke

Table

II. Average

total

blood

loss

from

fracture

and

Average

Stable
Unstable

.:1
Fig.

fractures

Table

(Grades

fractures

III.

1 Sand

(Grades

Complications

2)

3 to 5)

2.3

3.0

3.1

3.3

Jewett
nail-plate
(per cent)

Richards
screw-plate
(per cent)

wound

infection

1.9

3.7

0.9

infection

venous

thrombosis

and

original

317

months

of

injury

morbidity,

patients
operation

and operation
The

compared

measured
in the

two

than
the transfusion
1981). The total blood
estimated
operation,
haemoglobin
and 48
estimate

A similar

in both

groups

proportion
died

of the

within

three

from
(Table
blood

causes
I).
loss at

attributable
operation

was

not

to

the

groups

as it is frequently

much

less

and Ainscow
operation
was

by adding
to the amount
of blood transfused
at
one unit for each gram
per decilitre
that the
concentration
dropped
between
admission
hours
was

after
slightly

the operation.
larger
in the

The average
Richards
group

of this
and in

incidence
(Table

after
the

for

weeks

six

had

operation.

Jewett

operation
inadequate

after

received

more
fewer

evidence

superficial

of deep

were

in the

the

and
venous

confined

because

two

bedsores

Six patients

for

in the group
treated
were assisted
to stand

The

patients

ones,

nail-plates

be

8.4

slightly

no deep

after
to

Most

of clinical
III).

with

considered

II).

group
but

treated

hours

requirements
(Hall
loss from injury and

Richards

Mobilisation

patients
plates

10.7

(Table

infections

a similar
thrombosis

RESULTS
Mortality

0.9

retention

The

with
maximal
the barrel.

1.9

Urinary

wound
7

5.6

0.9

unstable
fractures
units of blood.

Fig.

1 .9

0.9

Deep

unstable
lracture
of the screw
within

1.8

failure

Jaundice

of an
shortening

5.

Cardiac

Chest

(units)

Richards
screw.plate

Stroke

Union

loss

Jewett
nail-plate

Bedsores
Superficial

blood

of the operations

Complications

operation

group
to bed

fixation

was

weight-bearing.

with the
and walk

All

Richards
screwwith a frame
48

operation.

speed

and

ease

with

which

patients
achieved
independent
was assessed
by the physiotherapist

previously

walking
and

mobile

with the
two groups

frame
were

defined : satisfactory
(walking
with a frame
and with
minimal
supervision
within
two
weeks),
and
slow
(walking
with a frame
and support
of one or two people
after two weeks).
Of the patients
with unstable
fractures,
satisfactory
mobilisation
was seen in 55 per cent of those
treated

with

the

Jewett
THE

nail-plates

JOURNAL

OF BONE

and
AND

85

per

JOINT

cent
SURGERY

of

TREATMENT

those
there

treated
with the Richards
screw-plates.
was little difference
between
the two

percentage
of patients
satisfactorily
mobilised
with the Jewett
device
the

Richards

from

dependent
length

with
stable
fractures
who were
(82 per cent in the group
treated
and 88 per cent in that treated
by

hospital.

factors
of hospital

follows
: admitted
three
weeks;
all
their
previous
admitted
from
weeks;
dation
each

To
changes

in

four

categories

inter-

accommodation

accommodation
home and returned

treatment

of the
were

and
defined

as

from home
and returned
home
within
patients
discharged
from
hospital
to
within
home

from home
to long-stay

amongst
group

categories

8). Of unstable

FRACTURES

The

others

265

OF THE FEMUR

were

still less mobile

and

needed

a walking

aid.

Clinical

and radiographical

results.

was assessed
radiographically
Jensen
( 198 1 ), thus radiographical

Failure

using

the
failure

of stabilisation
same criteria
was defined

three factors.
First, varus displacement
of the fracture
or
evidence
ofloosening
ofthe
implant
in the femoral
head.
(Varus
displacement
was defined
as an increase
in the
angle between
the implant
and the femoral
neck of more
than
10 degrees
in order
comparing
anteroposterior
femur
chanical
the nail,

in different

to minimise
radiographs

rotational

inaccuracies
taken
with

positions.)

Secondly,

And

finally,

axial

penetration

ofthe

femoral

by the

implant.

fractures

Shortening
of the Richards
screw
within
the barrel
is regarded
as normal
(Figs 9 and 10) and axial impaction
ofthe
femoral
head on the Jewett
nail without
penetration
was not regarded
as failure.

steady
increase
in the
on hospitals
or social

1978).

a)
U)
C,
U

0
.0

C
fractures

B
Unstable

C
fractures

Fig. 8
Discharge
from
hospital:
Grade
A were
admitted
from
home
and
returned
home
within
three
weeks;
Grade
B were
returned
to preoperative
accommodation
within
three weeks;
Grade
C were admitted
from home
and returned
home
later than three
weeks;
Grade
D were
admitted
from
home
or sheltered
accommodation
and discharged
to
long-term
nursing
care.

Follow-up.
Non-union
treated
with the Jewett
with
weeks

occurred
twice
among
device and once in those

the Richards
device.
Delayed
occurred
once
in each
group.

rarely

clinically

treated

with

ofstabilisation.
group
was
radiographical

evident

the Jewett

in either

device

those
treated

union
beyond
Shortening

group.

it was confined

In

the

12
was
group

to failures

Only one younger

man from the Richards
considered
to need
a shoe
raise.
Marked
shortening
(maximum
two centimetres)

occurred
in 14 per cent ofthose
treated
with the Richards
device.
External
rotation
deformity
was found
only in
patients
with failures
of fixation.
At three months,
with
fractures
healed,
about
half the patients
in each group
recovered
VOL

65-B.

the
No.

mobility

3. MAY

1983

that

they

had

before

me-

screw).

B
Stable

in
the

failure
of the implant
(bending
or breaking
of
detachment
of the plate
or dislocation
of the

as
by

is shown

with the Richards

device
weeks,
and half as many
bed. This has important

in containing
the
patients
dependent

(Yellowlees

three
weeks;
later than three

or sheltered
accommonursing
care.

these

(Fig.

three
times
as many
treated
returned
home
within
three
were discharged
to a long-stay

services

account

of

distribution

implications
number
of

take

stay,

and admitted
and discharged

The

However,
groups
in the

device).

Discharge

for

OF INTERTROCHANTERIC

operation.

Fig. 10
Slight
impaction
of the screw
the Richards
screw-plate
has
union
of an unstable

within
the barrel
allowed
uneventful
fracture.

of

head

G. H. HEYSE-MOORE,

266
Table

IV.

Radiographical

and

clinical

Radiographical
(per

A. G.

McEACHERN,

failure

rate and

failure

re-operation

Clinical

cent)

(per

JNP

D. C. JAMESON

EVANS

rate

failure

Re-operation

cent)

(per

cent)

RSPt

JNP

RSP

JNP

RSP

21

10.5

44

17

11

30

25

Grade3

58

12

26

8.2

Grade4

77

GradeS

88

23

54

19

21

19

75

14

25

1 1.1

18

9.7

23

7.4

13

6.5

Stable
Grade

Grade2
Total

stable

8.5

Unstable

Total

unstable

Allcases
S

Jewett

Richards

Radiographical

group

54

9.3

26

4.1

nail-plate
screw-plate

failures

are

defined

separately

as a

Table V. Mode

of failure

in the two groups

in which

the aims of fracture

stabilisation
by
internal
fixation
have
not been
achieved.
This
is
important
as a measure
of the reliability
of the implant
but clearly
many of the patients
will achieve
perfectly
clinical

satisfactory

results.

Mild

degrees

of

bending
of nails or even central
axial
are often symptomless.
failure is defined
as those patients
in whom
radiographical
failure
of fixation
caused
clinical
symptoms of pain, immobility
or deformity.
This clinical
rate
of failure is not the same as the re-operation
rate as many
were

considered

too ill for further

operations

comfortable
in bed or in a wheel-chair.
The percentages
ofclinical
or radiographical
failures
are shown
in Table IV. In the stable group both clinical
and radiographical
failures
were abolished
by the use of
the Richards
screw-plate.
In the unstable
group failure of
is

reduced

five-fold

and

clinical

failure

halved.
Re-operation

patients

was

treated

with

carried

the

out

in

Richards

6.5 per cent of those

device

and

in 13 per

cent treated
with
the Jewett
device,
and the clinical
outcome
was eventually
successful
in 57 per cent of the
former and 66 per cent of the latter.
The mode of failure of fixation
of the two implants
is shown
in Table V. It can be seen that the proportion
of
mechanical

failures

is similar

in both

in both groups are

by the inadequacy
of the bone. Thus
rate with the Richards
screw-plates
design of the Richards
implant,
which
of the fragments,
is superior
in
majority

of failures

groups

but

failures

cent)

Jewett

Richards

nail-plate

screw-plate

bone

84

80

mechanically

16

20

Implant

cut through

Implant

failed

inadequate
fractures.

bone

stock

that

the

caused essentially
the smaller
failure
implies
that the
allows for collapse
dealing
with
the

which

is found

in many

of these

DISCUSSION

or

were

stabilisation

(per

varus

displacement,
penetration
Clinical

patients

Radiographical

This study showed

that in our hands a one-piece
nailplate was not as reliable
a method
of fixation
of stable
intertrochanteric
fractures
as was suggested
by Jensen
(1981).
The Richards
screw-plate
on the other
hand
proved
an entirely
reliable
method
of fixation
of stable
fractures
even with imperfect
placement
of the screw.
In unstable
fractures
the one-piece
nail plate
is
recognised
to have a rate of technical
failure of 48 per
cent(Jensen
1981). The Richards
screw-plate
has reduced
our overall
rate of clinical
failure
three-fold
and our
stabilisation
failure rate five-fold.
Ofthe ten failures with
this device seven were in Group 5 fractures.
Of the three
that occurred
in Group 3 fractures
two could be ascribed
to technical
error and one to gross osteoporosis.
This
degree of reliability
suggests
that only Group
5 fractures
and those
Group
3 and 4 fractures
with technical
imperfections
of implant
placement
or grossly deficient
bone stock need follow-up
after discharge
from hospital
iftreated
with a Richards
screw-plate
whereas
all patients
treated with Jewettnail-plates
need atleast one outpatient
THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

TREATMENT

OF INTERTROCHANTERIC

FRACTURES

visit. This has significantly

reduced
the outpatient
clinic
load from this fracture
with considerable
savings
in
ambulance
use, radiographic
costs and clinic time.
In unstable
fractures
the decreased
rate of failure
was accompanied
by a three-fold
increase
in the number
of patients
discharged
home within
three weeks and a
halving
of the number
of patients
requiring
transfer
to
long-stay
beds. This saving in bed occupancy
more than
off-sets the extra cost of the implant.
We have eschewed
statistical
comparison
of the
overall
results
between
these
two series
and those

presented

267

OF THE FEMUR

in other

papers

because

the

overall

results

in

any series ofintertrochanteric

fractures
are influenced
by
a number
ofvariables.
These include the population
from
which they are drawn
and the locally available
nursing
and rehabilitation
facilities
which do not lend themselves
to objective
analysis.
However,
in the circumstances
prevailing
in Exeter the use of the Richards
screw-plate
for intertrochanteric
fractures
has made a considerable
contribution
to reducing
the three problems
of failure of
fracture
fixation,
blocking
of acute beds and burdening
of outpatient
facilities.

We would like to express our gratitude

to Mr P. J. Scott for his considerable
help in the preparation
of the manuscript.
to the consultant
orthopaedic
surgeons
at the Royal Devon and Exeter Hospital
for allowing us to review their patients,
photographic
staff for their help in retrieving
and recording
the information.

Our thanks are also due

and to the secretarial
and

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VOL. 65-B,

No. 3, MAY

1983