From Koch’s Bone Biomechanical Analysis to Contemporary Proximal Femur Fracture Management

Abstract

This article presents a current and comprehensive review of the biomechanical forces on the proximal femur, as preliminarily presented by Koch’s cornerstone work
on the bone architecture of the proximal femur. His work reflected on the complexity of proximal femur fractures and subtrochanteric fracture management in parallel
with implant evolution and classification. Multiple ways of classifying subtrochanteric fractures exist, however, there is not one classification system that is used to
guide operative management. The management of subtrochanteric fractures is surgical fixation which involves intramedullary nailing and plating (e.g., fixed angle
and locking). The gold standard management is intramedullary nailing with antegrade and retrograde nail options. Though antegrade nailing presents an advantage
due to the deforming forces, retrograde nailing of proximal femur fractures offers less operative time and blood loss. Similar outcomes have been reported between the
two methods. Decision making when contemplating antegrade versus retrograde nailing for femur fractures is mostly driven by body habitus and associated injuries,
and not by fracture distance of the proximal femur to the trochanteric region