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604 W. R. KRAUSE, M. H. POPE, R. J. JOHNSON, AND D. G. WILDER
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Treatment of Intertrochanteric and Subtrochanteric Fractures
of the Hip by the Ender Method
BY HEINZ KUDERNA, M.D.*, NIKOLAUS BOHLER, M.D.*, AND DAVID J. COLLON, M.D.t, VIENNA, AUSTRIA
ABSTRACT: Ender’s method of intramedullary fixa-
tion of intertrochanteric and subtrochanteric fractures
is described. Ender’s nail is a pre-bent flexible steel
nail with a diameter of 4.5 millimeters. Three to five of
these nails are inserted from a small incision proximal
to the medial epicondyle of the femur into the medullary
canal. They are passed through the femur across
the fracture site and into the head of the femur, where
they diverge. They are in the lines of force and therefore
are not subjected to bending moments. The frac-
ture fixation allows immediate weight-bearing. This
method of fixation was used in a series of 203 patients.
Their average age was sixty-eight years; the mortality
rate was 10.3 per cent. In 3.9 per cent superficial infec-
tions occurred, but in no case was there a deep infec-
* Lorenz B#{246}hlerKrankenhaus, 20, Donauesehingenstrasse 13, A
1200 Wien, Austria.
1- Henry Ford Hospital. Detroit, Michigan.
Front the Loren: BiihIer Krankenhaus, Vienna
tion involving the bone. Functional return (walking)
was achieved in all of the survivors who were able to
walk at the time of injury, and there were no non-
unions.
Ender first described the use of flexible nails inserted
via the medial condyle of the femur for the treatment of
intertrochanteric and subtrochanteric fractures 9,1O,tl,21
The procedure has found many advocates 4.13.t7.tS,22, but
to our knowledge only one description of it, not generally
available, has been published in English 2 In the present
report we describe the method and the results we obtained
with it in a series of 203 cases.
The morbidity and mortality associated with inter-
trochanteric and subtrochanteric fractures of the femur
remain high, because the patients with this injury gener-
ally have a reduced tolerance for bed rest, lengthy opera-
tions, and blood loss 9,14#{149}
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VOL. 58-A, NO. 5. JULY 1976
TREATMENT OF INTERTROCHANTERIC AND SUBTROCHANTERIC FRACTURES OF THE HIP 605
The Ender method substantially reduces the length
and severity of the operation necessary for fixation of these
fractures, and allows immediate weight-bearing even in
most patients with so-called unstable fractures. The opera-
tion has the additional advantage of ease of performance.
Clinical Material
From August 197 1 to December 1 973. 203 patients
with fractures of the base of the neck of the femur, or
intertrochanteric or subtrochanteric fractures, were treated
by Enders method at the Lorenz B#{246}hler Krankenhaus in
Vienna. There were seventy-two men and 131 women,
with an age range of from twenty-one to ninety-four years
(average, sixty-eight). Of the 203, 146 patients (72 per
cent) were over seventy years old (Table I). There were
ninety-eight right hips and 105 left hips involved. Most of
the fractures ( I 79) had occurred less than twenty-four
hours before admission to the hospital. The-other twenty-
four patients were admitted at from twenty-four hours to
twenty-six days after injury.
In 190 of our patients (94 per cent), the fracture re-
suited from a minor fall. Only thirteen patients had other
associated fractures or injuries. However, many patients
had medically important conditions, such as cardiovascu-
0-29 30-39
nail-plate combination is used (Fig. I ). The anatomical
distribution of the fractures was as follows: base of the
neck , three; intertrochanteric , 159; pertrochanteric , ten;
spiral subtrochanteric , ten ; and combined intertrochanteric
and
ing
subtrochanteric
five fractures
(four-fragment),
were ‘ ‘reversed’
sixteen.
‘ , following
The remain-
Evans’ terminology:
that is, the fracture was parallel to the neck of
the femur and extended from above the lesser trochanter to
below the trochanteric tubercle.
Method
We consider the optimum time of operation to be
twenty-four to forty-eight hours after injury, after the pa-
tient’s general condition has been stabilized. During this
period of delay the fracture is immobilized by skeletal
traction.
Under general or spinal anesthesia the patient is
placed on a fracture table in the supine position. The frac-
ture is reduced as far as possible by traction, abduction,
and inward rotation. For control of the reduction and inser-
tion of the nails we use two image intensifiers simulta-
neously. This greatly facilitates the operation, but the
method can be followed as well by using one image inten-
sifier.
TABLE I
AGE DISTRIBUTION OF OUR PATIENTS (IN YEARS)*
40-49 50-59 60-69 70-79 80-89 90-99
Male 2 (2) 2 (2) 1 1 (9) 8 (5) 14 (12) 22 (14) 1 1 (5) 2 (0)
Female 0 0 0 7 (6) 13 (6) 54 (31) 45 (14) 12 (3)
-.Total 2 (2) 2 (2) I I (9) IS (I I) 27 (18) 76 (45) 56 (19) 14(3)
eight years.
* Numbers in parentheses are the number of patients followed (109) of the total of 203 operated on. The average age of both groups was sixty-
lar disease ( 125 patients). pulmonary disease (forty-seven
patients), or diabetes mellitus (twenty-five patients). In
107 patients the initial roentgenograms showed senile os-
teoporosis. There were three pathological fractures due to
metastasis of malignant tumors.
The results in all 203 patients were evaluated as to
complications, mortality, and fracture healing. For late
results contact with all patients was attempted, but only
sixty-eight of them could be followed. To the best of our
knowledge, forty-six of the 203 patients had died, and
many others were unable to return for follow-up because
of their general condition. Adequate follow-up roent-
genograms and clinical findings were available for forty-
one patients who did not return for re-examination. There-
fore, we could evaluate the late results of a total of 109
patients (Table I).
We differentiated the following types of fractures ac-
cording to their stability and exact anatomical position.
Sixty-three of 203 fractures (3 1 per cent) were so-called
unstable fractures 12 while the rest were classified as
stable. Because fixation in Ender’s method is along the
lines of force in the femur, the integrity of the medial or
posterior wall is not as important for stability as when a
An eight-centimeter longitudinal skin incision is
made from the adductor tubercle proximally. It is devel-
oped anterior to the adductor magnus and posterior to the
vastus medialis, to reach the medial surface of the femur.
About three centimeters proximal to the adductor tubercle,
a transverse small branch of the medial superior genie ulate
artery is seen overlying the periosteum of the femur, and at
this point the surface of the bone is perforated by a Stein-
mann pin. This hole is widened to I .5 centimeters by a
reamer.
The necessary length of the first nail is decided by
placing a nail over the drapes parallel to the femur and
checking its position with the image intensifier. Three to
five Ender nails (Fig. 2) are then inserted in the medullary
canal and guided across the fracture site. The nails are 4.5
millimeters in diameter (Fig. 2) and are available in
lengths ranging from thirty-six to thirty-nine centimeters.
They are stiffer than the conventional Rush rod and are
slightly curved. The tips are made to diverge by rotating
the axis of the pin during insertion. The amount of curva-
ture of the pin can be increased if needed with a bending
iron. If necessary, additional reduction can be accom-
pushed with the first nail (Fig. 3) by catching the neck of

606 HEINZ KUDERNA, NIKOLAUS BOHLER, AND D. J. COLLON
case.
-
FIG. 1
Vnstahle intertrochanteric fracture stabilized ss oh Ender nails in the lines of force. Note the fragmentation of the medial and posterior cortex in this
the feniur with the tip of the nail and rotating the nail to
bring the fragments into anatomical position. At least
three nails are then impacted in the head of the femur so
that they diverge. They should reach to within 0.5 mil-
II
Fi;. 2
The special tools needed: the nails are of vary ing lengths. Two of the
old type are positioned above two of the new type. Below, from left:
reamer, bending iron. inipactor. two different guiding tools for old and
new types of nails. mallet. and extractor.
limeterofthe hipjoint (Fig. 4). The distal ends ofthe nails
should lie proximal to the adductor tubercle: otherwise
they will cause symptoms in the knee.
A drain is inserted and the wound is closed. While the
patient is still on the fracture table, anteroposterior and
lateral roentgenograms of the hip and knee are made. The
extremity is then placed in a foam-rubber splint.
Osteotoznv of the Greater Tro’hanter
In cases of long vertical fracture and proximal dis-
placement of the distal fragment. especially in porotic
bone, shearing stress may develop if this method is used.
For these cases, B#{246}hlersuggested percutaneous osteotomy
of the greater trochanter . It allows for valgus and medial
displacement of the femur. increasing the stability of the
reduction (Fig. 5). The total duration of the operation is
only extended for from three to five minutes by the os-
teotomy. This osteotomy was done in twenty-two of our
patients: in eighteen. for intertrochanteric fractures; in
two, for spiral subtrochanteric fractures; and in one each,
for a pertrochanteric and a four-fragment fracture.
Subtrochanteric transverse fractures were stabilized
in the same manner as intertrochanteric fractures in our
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TREATMENT OF INTERTROCHANTERIC AND SUBTROCHANTERIC FRACTURES OF THE HIP 607
t
FIG. 3
Reduction is accomplished by rotating the first nail. which can be
removed after stabilizing the fracture with the second nail.
series but the spiral subtrochanteric and the four-fragment
fractures required additional stabilization . Additional
skeletal traction was used for six weeks in six patients.
Additional nails from the lateral condyle of the femur into
the greater trochanter also were used in six patients.
Additional circumferential wires were needed in two
cases. Those fractures were exposed, reduced, and
stabilized with two to four circumferential wires, follow-
ing which the nails were inserted in the conventional man-
VOL. 58-A, NO. S. JULY 976
FIG. 4
The nails are impacted in the head of the femur so that they diverge.
ner. In all of the four-fragment fractures, additional Ender
nails were inserted from the lateral side of the knee to
reach the greater trochanter.
For prevention of pulmonary embolism, immediate
preoperative heparin (15,000 international units per day)
was administered, followed immediately after the opera-
tion by acenocoumarol, which was continued for three to
four weeks following surgery or at least until the patient
was fully mobilized.
Postoperative Treatment
The patients were made to walk as early as possible
after removal of the drain on the second day. Although the
Ender method allows immediate full weight-bearing, we
trained the patients to use crutches as a safety precaution.
The patients were discharged as soon as they were able to
walk with crutches.
Some of the patients who had come to us from other
hospitals or from nursing homes returned to these institu-
tions for postoperative treatment. The patients treated
postoperatively in our hospital were seen at intervals of
two to four weeks.
Normally the nails were not removed unless they
caused symptoms.
Mobilization and Hospitalization
Of the 182 patients who survived the time of hos-
pitalization, 176 regained walking ability. Six patients
remained limited to a bed-chair existence, as they had
been before the injury.
The average time until the patients could sit beside
the bed was three days; the time until they were able to
walk was five days in those patients in whom Ender’s
procedure was performed alone or in combination with
osteotomy of the greater trochanter. When any additional
operative stabilization had been required, the average time
to ambulation was six days, even in patients with fourfragment
fractures. If additional skeletal traction had been
used the patients were sitting beside the bed by the seventh

608 HEINZ KUDERNA, NIKOLAUS BOHLER, AND D. J. COLLON
week, on average, and walking by the eighth week. The
average hospitalization for the entire series was eighteen
days.
Mortality and Complications
Twenty-one patients died during the period of hos-
pitalization. The mortality rate, therefore, was 10.3 per
cent. There were no intraoperative deaths. Two patients
died within twelve hours of surgery. one of cardiac de-
compensation and one of fat embolism. Of the other nine-
teen patients, three died after massive pulmonary em-
FIG. 5
were seven cases of local infection at the site of the mci-
sion, all following necrosis of the skin edge. All resolved
with local treatment. There was no case of infection at the
fracture site.
In two patients there was infection at the site where
the tibial nail had been inserted for traction prior to
surgery. In both cases these infections resolved without
complications.
The only serious infections were those in pressure
sores. These occurred in fifteen patients. Eight patients
already had pressure sores at the time of admission to our
Osteotomy of the greater trochanter was done in this case to allow medial displacement of the distal fragments.
bolism prior to the time when we began to use heparin and
acenocoumarol for hypocoagulation. Pneumonia con-
firmed on roentgenograms was present in eight patients,
and led to death in four. Three of four patients with renal
insufficiency died; eight patients died of cardiac decom-
pensation; and two, of marasmus.
A local hematoma at the site of the incision over the
adductor tubercle had to be evacuated and drained in five
patients. In four the fluid was sterile. and in the fifth the
organism cultured was considered a contaminant. There
hospital; in the other seven patients their general condition
had not allowed them to become ambulatory at the usual
time.
One patient sustained a supracondylar fracture of the
osteoporotic femur upon getting out of bed for the first
time. It healed after ten weeks of bed rest.
Reoperation was performed in five patients between
the fourth and forty-second day after the first operation. In
four there was a loss of reduction, and in three of them it
was attributable to improper technique. In two patients the
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VOL. 58-A, NO. :S. JULY 976
TREATMENT OF INTERTROCHANTERIC AND SUBTROCHANTERIC FRACTURES OF THE HIP 609
FIG. 6
The nails are not impacted sufficiently and do not diverge enough.
This niay cause loss of reduction.
nails were not sufficiently divergent to provide rotational
stability. In one patient with a pertrochanteric fracture the
nails had not been impacted deeply enough in the head of
the femur (Fig. 6). The fourth patient had a four-fragment
fracture treated before we began to use additional stabili-
zation. In the fifth patient, overly long nails had been
chosen and they had to be changed because of irritation
at the knee.
In sixteen patients, one or more of the nails had to be
renioved before osseous healing was adequate because of
irritation at the knee; none of these lost the reduction posi-
tion or required reoperation. In four of these cases the
nails were too long, and in four others the nails slid dis-
tally because at the time of operation the cortex above the
point of insertion of the nails was broken. In the eight
cases in which the nails had to be removed prematurely,
they had slid distally because of the osteoporotic bone and
the large medullary canal, and because too few nails were
used.
In seventeen patients the nails were removed after
O55OU5 healing was adequate.
Late Results
The average length of follow-up of the patients who
were seen for postoperative treatment was 1 3 1 days. In
sixty-eight cases it was possible to get roentgenographic
and clinical findings in special examinations for this study,
fourteen to forty months after operation.
Union ii,ic/ NO??- Union
Ender’s method allows immediate full weight-
hearing. and therefore weight-bearing is not dependent on
union. On the average, the first roentgenographic evidence
of bridging callus was found after six weeks. In five im-
pacted intertrochanteric fractures and in one fracture
of the base of the neck of the femur, primary osseous
healing occurred without any surrounding callus appearing
on the roentgenogram. In all other cases the fracture gaps
were closed by callus after ten to twelve weeks and had
disappeared after sixteen to eighteen weeks.
There were no cases of delayed union or non-union.
Loss of Reduction
In one case varus angulation after primary reduction
had increased from 10 to 30 degrees. This patient had a
fracture of the base of the neck with necrosis of the
femoral head. As a result of insufficient primary reduction,
we found unchanged varus angulation of 10 degrees in
thirteen patients and of 20 degrees in two patients. In three
patients with a good reduction there was 10 degrees of
varus and in one there was 20 degrees. In one other pa-
tient, residual varus angulation of 10 degrees increased to
20 degrees.
As a result of loss of reduction we found valgus de-
formity in twelve patients. Seven patients had 10 degrees
of valgus and two, 20 degrees, although the reduction
roentgenograms showed no valgus. Three patients had 30
degrees of valgus angulation on end-result evaluation after
showing 20 degrees on the reduction roentgenograms.
There was no significant difference between the types
of fractures as to which lost position most frequently. Four
of the twelve patients with increased valgus deformity had
supplemental osteotomy of the greater trochanter.
After intentional stabilization in valgus angulation
( I 0 degrees in twenty-five patients, 20 degrees in fourteen,
and 30 degrees in four), thirteen patients who demon-
strated valgus on reduction roentgenograms lost some (or
all) of that valgus on end-result evaluation. In seven pa-
tients the end result was no valgus (reduction of 10 de-
grees), and in two the same end result followed a 20-
degree valgus reduction. In four patients the end result
was 10 degrees of valgus while the reduction roentgeno-
grams showed 20 degrees.
The only rotatory malalignment we encountered was
that of external rotation as a result of loss of reduction in
four patients. One had 20 degrees ofexternal rotation after
accurate rotatory reduction. Two had 30 degrees of external
rotation after 10 and 20 degrees of post-reduction rota-
tion. The fourth patient had 40 degrees ofexternal rotation
after a post-reduction position of 20 degrees.
No type of fracture showed a significant predilection
for loss of reduction as regards rotation. In one case the
nails had been too short, while in three the nails had not
been inserted so that they would diverge in the head of the
femur. As a result of insufficient primary reduction we
found external rotation of 10 degrees in thirty more pa-
tients and of 20 degrees, in nineteen. In thirty-nine pa-
tients there was shortening of the extremity, and in five the
extremity was elongated. In all cases the elongation was
caused by overcorrection in valgus combined with os-
teotomy of the greater trochanter.
Necrosis of the Head of the Fenur -
Degenerative Arthritis
In one of the fractures of the lateral neck which had
healed primarily 240 days after the first operation, the hip

610 HEINZ KUDERNA, NIKOLAUS BOHLER, AND D. J. COLLON
joint had to be replaced by a total endoprosthesis because
of total necrosis of the head of the femur. Three other
patients had minimum deformities of the head, diagnosed
as being the result of aseptic necrosis.
0 Ankylosis in malposition
B C
Range of Motion Gait
1 Clinical ankylosis with minimum or no
malposition
Two-thirds of the patients were completely free of
2 Flexion of 40 degrees with minimum or
no abduction
3 Flexion of 40 to 60 degrees
4 Flexion of 60 to 80 degrees, patient can
tie his shoelaces
5 Flexion of 80 to 90 degrees, abduction
of 25 degrees
0 Bedridden
6 Flexion more than 90 degrees, abduction 6 Normal
of 40 degrees
I Few yards with crutches
2 Time and distance very limited with or
without canes
3 Less than 1 hr. with a cane, difficult
without a cane
4 More than I hr. with a cane, short
distances without a cane
5 Without a cane, but a slight limp
* Sum of A, B. and C: 0 to 8 = not satisfactory, 9 to 12 = satisfactory, 13 to 16 = good. and 17 to 18 = very good. (For the sum, the average value
of A is taken.)
Degenerative arthritis of the hip joint following oper-
ation developed in eight additional cases, in all of them to
a minimum degree. There was no significant difference
between the types of fractures as to predilection for de-
generative changes.
To quantitate the clinical findings in our patients we
used a modification of the system described by Merle
d’Aubign#{233} for evaluation of fractures of the acetabulum
(Table II). According to this scheme of grading, results
were very good in 52 per cent, good in 32 per cent, satis-
factory in 13 per cent, and unsatisfactory in 3 per cent.
Two-thirds of the patients could walk without a cane.
Half of these regained a normal gait; shortening of the
extremity caused the others to limp slightly. The regained
mobility of the hip joint was adequate in most cases. Only
one patient was unable to tie his shoelaces or to flex more
than 60 degrees at the hip, and only two patients had a
flexion contracture of more than 20 degrees.
The main advantages of Ender’s method are:
I . Favorable mechanical conditions are attained be-
TABLE II
CLINICAL RESULTS: CLASSIFICATION OF HIP FUNCTION (MERLE D’AUBIGNE)5
A
Pain
Knee Hip
0 0 Severe, spontaneous
I I Severe, disturbing sleep
2 2 Severe on attempting to walk,
prevents all activity
3 3 Tolerable, permitting limited activity
4 4 Only after some activity, disappears
quickly with rest
5 5 Slight or intermittent on starting to
6 6 Nopain
walk, but lessening with normal
activity
pain. In four patients with leg-length discrepancy, symp-
toms developed in the lumbar spine. In no case did any
rotatory malalignment disturb the subjective result. Occa-
sional pain in the region of the knee occurred in one-third
of the patients and was caused by protrusion of the distal
ends of the nails above the condylar surface. This symptom
did not occur when we correctly determined the point
of insertion and the length of the nails, taking into consid-
eration the expected shortening at the fracture site and
countersinking the nails.
Discussion
cause the intramedullary position of the nails corresponds
to the lines of force. The stress on the nails is therefore
axial and the bending moments are minimized. This al-
lows immediate weight-bearing even in cases of unstable
and subtrochanteric fracture. A nail-plate is subject to
greater bending moments than are Ender nails, when used
for the same fractures. Therefore, more complications will
occur with a nail-plate, and Evans showed that coxa vara
will develop in 26 per cent of cases. The more severe
deformities cause the device to bend or break. In our hospital,
in a series of 231 cases treated between 1965 and
1968 in which nail-plate fixation was used, there was a 10
per cent incidence of mechanical failure - either loosen-
ing of screws or bending or breaking of the plate.
Moreover, in 16 per cent of the cases the stability after
nail-plate fixation was not sufficient to permit early
weight-bearing.
2. There is minimum blood loss and minimum
operative stress to the patient. The procedure is tolerated
well even by patients in poor general condition. Our
mortality rate was 10.3 per cent as compared with the
average of 16.8 per cent that Evans calculated for 564
cases reported by eight authors, all of whom used nail-
plate devices.
3. The risk of infection is greatly reduced because
the incision is distant from the fracture site and there is no
extensive dissection of muscle. In our series 3.9 per cent
of patients had infections, all superficial, while Zifko re-
ported an infection rate of 8 per cent in a series of 775
intertrochanteric fractures after operative fixation with
other devices.
4. In comparison with K#{252}ntscher’s trochanteric nail,
rotational stability is improved because of the diverging
tips of the nails in the head of the femur. The K#{252}ntscher
nail, which is slightly curved and tubular and measures ten
millimeters in diameter, is inserted through the medial
condyle of the femur; it is guided across a subtrochanteric
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VOL. 58-A, NO. 5. JULY 976
TREATMENT OF INTERTROCHANTERIC AND SUBTROCHANTERIC FRACTURES OF THE HIP 611
or intertrochanteric fracture into the head of the femur.
Therefore, compared with Ender’s nail it has similar
mechanical advantages but is more difficult to insert be-
cause the nail is stiffer. With the insertion of the Ender
nails in the area of the metaphysis of the femur, the medial
collateral ligament is not injured as it is by the insertion of
the K#{252}ntscher trochanteric nail.
Because of the axial fixation of the fragments and the
immediate weight-bearing, a certain amount of shortening
can occur, especially in elderly patients with atrophic
bone. In most cases this did not affect the result. Second-
ary perforation of the head of the femur was found in only
4.4 per cent of the patients in our series, whereas it oc-
curred in 26.3 per cent treated with KUntscher’s method in
Povacz’s series. These perforations probably occurred
during operation and either were not recognized or sup-
posedly were corrected by retracting the nail a short dis-
tance. However, the nail might have perforated later,
through the preformed hole. Therefore, if perforation is
encountered, the nail should be completely withdrawn and
References
reinserted in a new position.
An objection frequently raised to operations using an
image intensifier is the amount of radiation received by the
operating-room personnel. We therefore measured the
amount of radiation by means of film dosimeters, and
found no direct radiation to the staff or surgeon because of
their distance from the radiated fracture site during the
procedure. The indirect radiation to personnel who used
lead aprons approached zero. The amount of indirect radi-
ation outside the lead aprons was a maximum of six mil-
liroentgens and averaged 4.2 milliroentgens per operation.
The tolerable dose of radiation of 100 milliroentgens per
month was not reached in any case.
An important factor in assessing a new operative
technique is the ease with which the average surgeon can
master it. The 203 operations reported here were per-
formed by different surgeons, many of them first or
second-year residents. Ender’s method is technically quite
simple. Using two image intensifiers, the operation can be
accomplished in an average of fifteen minutes.
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