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based on Evans classiﬁcation and the AO/OTA classiﬁcation, as
well as individual surgeon experience, inﬂuenced the method
of treatment (14, 15). Most AO/OTA 31-A1 and stable AO/
OTA 31-A2 fractures are treated with an HSSP at our facility, while unstable AO/OTA 31-A2 fractures are treated with
a CMN. Lastly, AO/OTA 31-A3 fractures are treated with a
CMN. Studies have deﬁned unstable fractures as those with
extension into the subtrochanteric region, comminution of the
lateral wall, comminution of the posterior-medial cortex, and
reverse obliquity types (16, 17).
Postoperatively, patients were weight-bearing as tolerated and
began working with physical therapists immediately. Patients
were discharged home with home health or were discharged
to a skilled nursing facility, nursing home, or rehabilitation
center, depending on physical therapy recommendations and
the amount of assistance available at home.
International Statistical Classiﬁcation of Diseases and Related Health Problems (ICD-9) codes were utilized to identify
patients with unspeciﬁed trochanteric fractures (ICD-9 820.20)
and intertrochanteric fractures (ICD-9 820.21). The medical
records were reviewed and data collected including medical record number, date of birth, gender, fracture type, surgery type,
mechanism of injury, surgery date, surgeon involved, bisphosphonate use, diabetic status, and smoking status. For all those
with subsequent proximal femur fractures, we recorded the time
that elapsed from initial to subsequent fractures. Digital radiographs were then reviewed for each fracture to conﬁrm fracture
type (pertrochanteric, intertrochanteric, subtrochanteric), note
surgery performed (HSSP, CMN), and classify the fracture types
according to the Evans and AO/OTA classiﬁcation system for
proximal femur fractures. After radiographic review, the subtrochanteric femur fractures were excluded from the data set.
Secondary variables were collected from the patient chart:
age, sex, cigarette smoking, bisphosphonate use, and history of
diabetes. Smoking status was classiﬁed based on a scale of 1 to
5: Grade 1 were patients who had never smoked or smoked <10
pack-years, Grade 2 were former smokers of 10 to 50 pack-years,
Grade 3 were former smokers of >50 pack-years, Grade 4 were
current smokers of <1 pack per day, and Grade 5 were current
smokers of >1 pack per day. Signiﬁcant smoking history was
deﬁned as Grade 2 or higher.
Descriptive statistics are reported as mean (standard deviation) or median (range) for continuous variables. Categorical
variables are described as counts and percentages. Outcome
variables were compared by contralateral fracture and ﬁxation
methods. Chi-square tests were used to compare two independent nominal variables. A logistic regression model was ﬁt to
the data. A P value of 0.25 was used to select variables for
the model, and the ﬁnal model selection used the methods of
stepwise, forward, and backward selection. Proﬁle likelihood
methods were used to calculate the conﬁdence intervals of the
odds ratios. Due to the retrospective nature of the data, a conditional logistic regression model using one-to-one propensity
score matching was performed to adjust for diﬀerences between
the ﬁxation groups. Patients were matched according to a propensity score calculated using a logistic regression model on type
July 2017

of ﬁxation as a response, with gender, diabetes status, fracture
type, bisphosphonate use, ﬁrst fracture classiﬁcation, and ﬁrst
fracture side used as covariates. The number of digits to match
in the probabilities was 0.001. A log-rank test was used for comparison of time to second fracture by ﬁxation technique. A level
of 0.05 was considered statistically signiﬁcant for all tests. The
software used was SAS/STAT, Version 9.4 of the SAS System
for Windows, and StatXact version 10.1. No external funding
sources were used for this retrospective review.
RESULTS
Following review of all medical records and radiographs,
1157 patients met inclusion criteria. Two of these patients had
subtrochanteric extension of their fracture and were excluded
from the analysis for a total of 1155 subjects. Of these, 103
(8.9%) patients had contralateral fractures. The study population included 841 (72.8%) females and 314 (27.2%) males
with an average age of 82.4 (10.3) years at the time of initial
hip fracture (Table 1). Four hundred and thirty (37.2%) were
managed with an HSSP and 725 (62.8%) were managed with a
CMN. Demographic data for these patients are listed in Table 2.

Table 1. Patient characteristics by occurrence of a second fracture
Second fracture
Variable

No
(N = 1052)

Yes
(N = 103)

P
value

Female

760 (72%)

81 (79%)

0.20

Age at first fracture (years)
Diabetes mellitus

83.9
79.5
(35.1-109.0) (51.6-108.0)

0.22

247 (24%)

23 (22%)

0.90

Never smoked/<10 pack-years

716 (68%)

70 (68%)

0.98

Current smoker <1 pack-years

56 (5%)

6 (6%)

Cigarette smoker

Current smoker >1 pack-years

29 (3%)

2 (2%)

10-50 pack-years

148 (14%)

16 (16%)

>50 pack-years

102 (10%)

9 (9%)

Bisphosphonate-yes

217 (21%)

32 (31%)

0.02

Pertrochanteric

880 (84%)

84 (82%)

0.58

Intertrochanteric

172 (16%)

19 (18%)

Cephalomedullary nail

668 (64%)

57 (55%)

Hip plate and side screw

384 (36%)

46 (45%)

A1

311 (32%)

39 (42%)

A2

569 (58%)

45 (48%)

A3

107 (11%)

9 (10%)

First fracture characteristics
Fracture type

Fixation type

0.11

Fracture classification*
0.13

*There are 75 missing observations for fracture classification.

Treatment of pertrochanteric hip fractures

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