1. Intertrochanteric Fractures
Presenter: Please look at notes to facilitate your talk—
There is too much content for one sitting
-edit to your needs—
Unanswered clinical issues and audience questions at end of lecture
THIS LECTURE IS WAY TOO LONG TO INCLUDE ALL, but is designed to be segmented and modified.There are slides with hints & suggestions on slides for the speaker, that can & should be deleted prior to presenting. Hope you find it useful
Michael R. Baumgaertner, MD
Original Authors: Steve Morgan, MD; March 2004;
New Author: Michael R. Baumgaertner, MD; Revised January 2007
Revised December 2010

2. Lecture Objectives Review: Introduce: Suggest: Understand & Optimize
Principles of treatment
Understand & Optimize
Variables influencing patient
and fracture outcome
Introduce:
Recent Evidence-
based med
Suggest:
Surgical Tips to avoid common problems

3. Hip Fracture PATIENT Outcome Predictors
Uncontrolled
Surgeon Controlled!
Pre-injury physical & cognitive status
Ability to visit a friend or go shopping
Presence of home companion
Postoperative ambulation
Postoperative complications (Cedar, Thorngren, Parker, others)

4. A public heath care cri$i$: 130,000 IT Fx / year in U. S
A public heath care cri$i$: 130,000 IT Fx / year in U.S. & will double by 2050…
4-12% fixation failure
1-2 units PRBC transfused
3-5+ days length of stay
Even when surgery is “successful”:
We must do better!!

5. Preoperative Management the evidence suggests:
“Tune up” correctable comorbidities
Operate within 48°; avoid night surgery
Maintain extremity in position of comfort
General versus spinal anaesthesia?
Zuckerman, JBJS(A) ‘95
Buck’s traction of no value (RCT)
Anderson, JBJS(B) ‘93
Randomized, prospective trials (RCTs): no difference
Davis, Anaesth & IntCare ‘81;
Valentin, Br J Anaesth ‘86

6. Comprehensive Management excellent evidence based single source:
Osteoporosis International
“Preoperative Guidelines and Care Models for Hip Fractures”
Volume 21, Supplement 4 December 2010
15 review articles covering virtually all of the clinical issues regarding management of geriatric hip fractures

7. Intertrochanteric Femur Anatomic considerations
Capsule inserts on IT line anteriorly, but at midcervical level posteriorly
Muscle attachments determine deformity

8. Plain Films Radiographs AP pelvis Cross-table lateral
ER Traction view when in any doubt!!
Plain Films
AP pelvis
Cross-table lateral

9. Factors Influencing Construct Strength:
Uncontrolled factors
Bone Quality
Fracture Geometry
Controlled factors
Quality of Reduction
Implant Placement
Implant Selection
Kaufer, CORR 1980
This lecture will examine each factor

10. Uncontrolled factor: Fracture geometry
“STABILITY”
The ability of the reduced fracture to support physiologic loading
Fracture Stability relates not only to the # of fragments but the fracture plane as well

11. Stable
Unstable
AO / OTA 31

12. Uncontrolled factor: Fracture geometry
Stable
Unstable

13. AO/OTA31A3: The highly unstable “pertrochanteric” fractures!
Uncontrolled factor: Fracture geometry
This is the real value of the the AO/OTA classification– it clearly identifies this most difficult pattern (Lateral fracture line BELOW the vastus ridge)
AO/OTA31A3:
The highly unstable “pertrochanteric” fractures!

14. Uncontrolled factor: Bone quality
A 33 year old pt with intertrochanteric fracture following a fall from height-
Note the dense, cancellous bone throughout the proximal femur;
Not at all like a geriatric fracture

15. Uncontrolled factor: Bone quality
83 yo white woman with unstable intertrochanteric fracture:
Note the marked loss of trabeculae

16. Implants must be placed where the remaining trabeculae reside!
Uncontrolled factor: Bone quality
Implants must be placed where the remaining trabeculae reside!

17. Can / Should we strengthen the bone-implant interface?
Uncontrolled factor: Bone quality
Can / Should we strengthen the bone-implant interface?
PMMA
12 to 37% increase load to failure
Choueka, Koval et al., ActaOrthop ‘96
CPPC
15% increased yield strength, stiffer
Moore, Goldstein, et al., JOT ‘97
Elder, Goulet, et al., JOT ‘00
Clinical Factors in 2010 influence use
delivery, cost, complications must be considered
Multiple studies have tried to show improvement in outcomes by injecting into the pathologically weak bone to improve holding power of implants.– although some strength improvements in lab, no one has shown improvement in clinical outcome, or cost effectiveness.
Hydroxy-apatite (HA) coated screws
Reduced cut out in poorly positioned fixation
Moroni, et al. CORR ‘04

18. Factors Influencing Construct Strength:
Uncontrolled factors
Fracture Geometry
Bone Quality
Surgeon controlled factors
Quality of Reduction
Implant Placement
Implant Selection
Need to get these right!!
Kaufer, CORR ‘80
Kauffer, CORR 1980

19. When employing sliding hip screws…
Surgeon controlled factor
Fracture Reduction
When employing sliding hip screws…
No role for displacement osteotomy
Limited role for reduction & fixation of trochanteric fragments (biology vs stability)
Surgical goal: Biplanar, anatomic alignment of proximal & shaft fragments
Mild valgus reduction for hinstability to offset shortening
RCT Gargan, et al. JBJS (B) ‘94
RCT Desjardins, et al. JBJS (B) ‘93

20. Fracture Reduction Discuss sequence of closed reduction steps
Surgeon controlled factor
Fracture Reduction
Discuss sequence of closed reduction steps
Consider adjuncts to fracture reduction Crutch… elevator… joystick…. etc.
Lever technique– read this article:

21. Fracture Reduction of Surgeon controlled factor
Double density of medial cortex is evidence of intussuscepted neck into shaft seen on lateral

22. Traction will not reduce this “sag” but a lever into the fracture will

23. Traction will not reduce this “sag” but a lever into the fracture will reduce it
Toggle back and forth to see reduction technique. It pulls the bone right out of the neck!

24. Fracture Reduction Surgeon controlled factor
The AP view before and after lever redution: the medial cortex is restored

25. Apex of the femoral head
Surgeon controlled factor: Implant position
Apex of the femoral head
Defined as the point where a line parallel to, and in the middle of the femoral neck intersects the joint

26. Screw Position: TAD X Tip-Apex Distance = +
Surgeon controlled factor: Implant position
Screw Position: TAD
Tip-Apex Distance = X ap +
lat

27. Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Surgeon controlled factor: Implant position
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95

28. Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Surgeon controlled factor: Implant position
Probability of Cut Out
Risk of Cut Out
Increasing TAD ->
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95

29. Logistic Regression Analysis
Surgeon controlled factor: Implant position
Logistic Regression Analysis
Multivariate (dependent variable:Cut Out)
Reduction Quality p = 0.6
Screw Zone p = 0.6
Unstable Fracture p = 0.03
Increasing Age p = 0.002
Increasing TAD p =
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95

30. Optimal Screw Placement
Surgeon controlled factor: Implant position
Optimal Screw Placement
Dead Center
and
Very Deep
(TAD<25mm)
Best bone
No moment arm for rotational instability
Maximum slide
Validates reduction

31. What’s the big deal? IM vs Plate Fixation
Surgeon controlled factor: Implant selection
What’s the big deal?
IM vs Plate Fixation

32. IM Fixation Recent History: Theoretical Biologic Advantages
Percutaneous Procedure
EBL, Muscle stripping, Complications, Rehab time?
Surgical wounds s/p ORIF with IM device

33. The First to Reach the Market
GAMMA
The First to Reach the Market

34. Gamma Clinical Results ± +++ +++
Advantages :
+++
+++
Complications :
Complications :
Bridle
Bridle
JBJS(B) '91
Williams
JBJS(B) '91
Williams
Injury '92
Injury '92
Boriani
Boriani
Orthopaedics '91
Leung
Orthopaedics '91
Leung
JBJS(B) '92
JBJS(B) '92
Lindsey
Lindsey
Aune
Trauma '91
Trauma '91
Aune
ActOrthopScan '94
ActOrthopScan '94
Halder
Halder
JBJS(B) '92
JBJS(B) '92

35. Gamma Nail vs. CHS Gamma Nail vs. CHS
Surgeon controlled factor: Implant selection
Gamma Nail vs. CHS
Gamma Nail vs. CHS
1996 Meta-analysis of ten randomized trials •
Shaft fractures: Gamma 3 •
x CHS (p < 0.001)
x CHS (p < 0.001) • •
Required Re-ops: Gamma 2
Required Re-ops: Gamma 2
x CHS (p < 0.01)
x CHS (p < 0.01) • •
IM fixation may be superior for inter/subtroch
IM fixation may be superior for inter/subtroch
extension & reverse obliquity fractures
extension & reverse obliquity fractures • • “ “
CHS is a forgiving implant when used by
CHS is a forgiving implant when used by
inexperienced surgeons, the Gamma nail is not”
inexperienced surgeons, the Gamma nail is not”
MJParker, International Orthopaedics '96
Parker, International Orthopaedics '96

36. No more increased risk with nails
Gamma nails revisited (risk of shaft fracture….) Bhandari, Schemitsch et al. JOT 2009
No more increased risk with nails

37. IM Fixation: Clinical Results
Surgeon controlled factor: Implant selection
IM Fixation: Clinical Results
RCT, IMHS vs CHS, N = 135
No difference for stable fxs
Faster & less bloody for unstable fxs
Fewer IM complications than Gamma
Weaknesses:
No stratification of unstable fractures
Learning curve issues
No anatomic outcomes, wide functional outcomes
Baumgaertner, Curtin, Lindskog, CORR ‘98

38. IM Fixation: Clinical Results
Surgeon controlled factor: Implant selection
IM Fixation: Clinical Results
Well analyzed RCT, IMHS vs CHS, N = 100
Longer surgery, less blood loss
Improved post-op mobility
@ 1 & 3 months *
Improved community ambulation
@ 6 & 12 months *
45% less sliding, LLD*
(* p < 0.05)
Hardy, et. al JBJS(A) ‘98

39. ? ? ! ! IM Fixation: Mechanical Advantages
Surgeon controlled factor: Implant selection
IM Fixation: Mechanical Advantages
IM Fixation: Mechanical Advantages ? ? ! !

40. Key point
It is not the reduced lever arm that offers the clinically significant mechanical advantage, but rather the intramedullary buttress that the nail provides to resist excessive fracture collapse*
* Reduced collapse has been demonstrated in most every randomized study that has looked at the variable

41. The nail substitutes for the incompetent posteromedial cortex

42. The nail substitutes for the incompetent lateral cortex
2 weeks
2 weeks
7 months
7 months
The nail substitutes for the incompetent lateral cortex

43. Iatrogenic, intraoperative lateral wall fracture
CHS: Unique risk of failure
Palm, et al JBJS(A) ‘07
Iatrogenic, intraoperative lateral wall fracture
31% risk in A2.2&3 fxs 22% failure rate
(vs. 3% overall)
A2 to A3 fx!
This failure mechanism does not exist with IM fixation, and must be protected with TSP (see next slide) 43

44. IM Fixation: Selected Clinical Results
Surgeon controlled factor: Implant selection
IM Fixation: Selected Clinical Results
RCT, IMscrew vs CHS, N = 436
less sliding, shaft medialization*
Ahrengart, CORR ‘02
RCT, IMscrew vs CHS, N = 46
5° in neck shaft 6 wks (all)
shaft 4mo *
Pajarinen, Int Orth ‘04
Improved post-op mobility (4 months)*
less sliding, shaft medialization*
RCT, IMscrew vs CHS, N = 108
(* p < 0.05)
Pajarinen, JBJS(B) ‘05

45. Surgeon controlled factor: Implant selection
CHS Improvements:
Trochanteric Stabilizing Plate (TSP) plate adjunct to limit shaft medialization
major (≥20mm screw slide) collapse
op time, blood loss
? complications, length of rehab
Madsen, JOT '98
Su, Trauma ‘03
Bong, Trauma ‘04

46. Reverse Oblique Fractures
Surgeon controlled factor: Implant selection
IM Fixation: Best Indications
Reverse Oblique Fractures
Intertroch + subtrochanteric fractures

47. Reverse Oblique Fractures
Surgeon controlled factor: Implant selection
Reverse Oblique Fractures
Retrospective review of 49 consecutive R/ob. Mayo: overall 30% failure rate
Poor Implant Position: 80% failure
Implant Type:
Compression Hip Screw: 56% failure (9/16)
95° blade / DCS: 20% failure (5/25)
IMHipScrew: 0% failure (0/3)
Haidukewych, JBJS(A) 2001

49. Reverse Oblique Fractures
Surgeon controlled factor: Implant selection
Reverse Oblique Fractures
PFN vs 95° sliding screw plate(DCS)
RCT of 39 cases done by Swiss AO surgeons
PFN (IM) vs Plate
Open reductions
Op-time
Blood tx
Failure rate
Major reoperations
All Significantly reduced!
Sadowski,Hoffmeyer JBJS(A) 2002

50. Recovery room control X-ray shows loss of medial support, but nail prevents excessive collapse

52. Intertroch/ subtrochanteric fxs
Surgeon controlled factor: Implant selection
Intertroch/ subtrochanteric fxs
Greater mechanical demands, poorer fracture healing

54. Long Gamma Nail for IT-ST Fxs
Surgeon controlled factor: Implant selection
Long Gamma Nail for IT-ST Fxs
Barquet, JOT 2000
52 consecutive fractures; 43 with 1 year f/u
100% union
81 minutes, 370cc EBL
The authors describe the key percutaneous reduction techniques that lead to successful management of these difficult fractures

55. Reduction Aids

56. Unstable Pertroch Fractures (OTA31A.3)
Surgeon controlled factor: Implant selection
Unstable Pertroch Fractures (OTA31A.3)
“Evidence-based bottom line:”
Unacceptable failure rates with CHS
Better results with 95° devices
Best results with I M devices*
Best “functional outcome” not known
347 articles reviewed: 10 relevant; 5 RCTs*
Kregor, et al (Evidence Based Working Group) JOT ‘05

57. CHS
AO / OTA 31

58. Grossly displaced Stable (31A.1) fracture treated with ORIF
Surgeon controlled factor: Implant selection
Grossly displaced Stable (31A.1) fracture treated with ORIF

59. Surgeon controlled factor: Implant selection
There is no data to support nailing over sideplate fixation for A1 fractures

60. CHS
????
AO / OTA 31
No data says nails are better for A1 fractures, a growing body of data supports nails for A3 fractures, the only real question is the A2 fractures
NAIL

61. Surgeon controlled factor: Implant selection
IM Fixation vs. CHS Randomized/prospective trial of 210 pts. Utrilla, et al. JOT 4/05
Patients
All ambulatory, no ASA Vs
Fractures
Excluded inter/subtrochs fractures (31A.3)
--excludes the fxs KNOWN to do best with IM
Surgeons
Only 4, all experienced
Technique
All got spinals, Closed reduction, percutaneous fixation
All overreamed 2mm, all got 130° x 11mm nail, one distal interlock prn rotational instability (rarely used)

62. Surgeon controlled factor: Implant selection
IM Fixation vs. CHS Randomized/prospective trial of 210 pts. Utrilla, et al. JOT 4/05
Results
Skin to skin time unchanged
Fewer blood transfusions needed with IM
Better walking ability in Unstable fractures with IM
No shaft fxs
Fewer re-ops needed in IM group (1 vs 4)
Conclusion
IM fixation or CHS for stable fxs
Unlocked IM for most Unstable fxs

63. SHS remains the “Gold Standard”
JBJS(A) 2010
SHS remains the “Gold Standard”
No difference:
Re-ops
Mobility
Residence
Transfusions
Hospital stay

64. However…. This is gold? Grossly underpowered (beta error)
/arm needed
Any patient eligible (age 42-99)
Used Long Nails
Outcome measures perfunctory
No X-rays
32% mortality
21% phone /proxy only
This is gold?
The outcomes measured were reoperation and death, gross ambulation levels, and living status. So, a patient that healed 3cm short with reduced offset that had been golfing and biking and now can only manage to shop weekly is a” perfect” result. This is not a study looking at quality of life of an active, elder patient, and one can not generalize to that population.

65. IM Hip Screws Author’s Opinion
Surgeon controlled factor: Implant selection
IM Hip Screws Author’s Opinion
Data supports use for unstable fractures
RCTs document improved anatomy and early function
Iatrogenic problems decreased with current designs and technique
Indicated only for the geriatric fracture
These larger (15-18mm) nails remove too much bone in non osteoporotics// geriatric fractures– I use standard medullary-cephalic nails for high energy young fractures

66. IM Hip Screw: Contraindications
Surgeon controlled factor: Implant selection
IM Hip Screw: Contraindications
young patients (excess bone removal)
basal neck fxs (iatrogenic displacement)
stable fractures requiring open reduction (inefficient)
stable fractures with very narrow canals (inefficient)

67. Technical Tips

68. Patient Set-up Position for nailing: Hip Adducted
Unobstructed AP & lateral imaging
Fracture Reduced(?)
Strong traction (without well leg countertraction) abducts fractured hip and prevents gaining proper entrance site

69. Strong traction (without well leg countertraction) abducts fractured hip and prevents gaining proper entrance site

70. The solution is the “Scissors position” for the extremities
Both feet in txn
Fx: flexed & add
Well leg extended & abducted
Lateral Xray: a little different, but adequate

71. Guide Pin Insertion

72. Guide Pin Insertion (Usually by hand…)
Ostrum, JOT 05: The entrance is at the trochanteric tip or slightly MEDIAL

73. Ream a channel for implant
Ream a channel for implant! (don’t just displace the fracture as you pass reamer through it)
Medial directed force prevents fracture gapping during entrance reaming

74. Achieve a Neck-Shaft Axis > 130°
Use at least a 130° nail
Varus Corrections
Advance nail
Increase traction
ABDUCT extremity!! (adduction only necessary at time of nail insertion)

75. Postoperative Management
Allow all patients to WBAT
Patients “self regulate” force on hip
No increased rate of failure
X-rays post-op, then 6 & 12 weeks
Koval, et. al,JBJS(A)’98

76. Epilogue: intertrochs
(Questions without good answers)

77. Unanswered questions
Where’s the evidence??

78. Minimally invasive PLATE fixation ??
2 hole DHS
Bolhofner
Dipaola
PCCP
Gotfried

79. Which nail design is best ??
Proximal diameter?
Nail Length?
Distal interlocking?
Proximal screw ?
Sleeve or no sleeve? Loch & Kyle, JBJS(A)‘98
One or two needed ?
Nobody knows!

80. Proximal fixation: 1 or 2 screws? Kubiak, JOT ‘04
IMHS vs Trigen in vitro (cadaveric) testing
Results:
No difference in fx sliding or collapse
No difference in rigidity or stability
Trigen with higher ultimate failure
Clinical significance??
Nobody knows!

81. Small Screws protect lateral wall Only relevant for plate fixation?
Gotfried, CORR ‘04
Im, JOT ‘05

82. But… the “Z effect”
7/70, 10% Werner-Tutschku, Unfall ’02
5/45 11% Tyllianakis Acta Orthop Belgica ‘04
Small Screws protect lateral wall from fx Only relevant for plate fixation?
Gotfried, CORR ‘04
Im, JOT ‘05

83. Long vs.short nails? -Nobody knows-
6% impinge/ 2% fx Robinson, JBJS(A) 05
Long vs.short nails?
Thigh pain from short, locked nails?
Periprosthetic fracture: Still an issue?
Anterior cortex perforation with long nails?
Cost/ benefit?
-Nobody knows-

84. Just when you think you know whats best-- Don’t forget Ex-Fix!
RCT n=40 Exfix +HA vs DHS
Faster ops, fewer txfusions, no comps
Moroni, et al. JBJS(A) 4/05 ?

85. Ex-fix (HApins) vs DHS Randomized/prospective trial of 40 pts
Ex-fix (HApins) vs DHS Randomized/prospective trial of 40 pts. Moroni, et al. JBJS(A) 4/05
Patients
65yo+ walking women with osteoporosis
Results
Faster operations with Fewer transfusions
Less post op pain, similar final function
No pin site infxs, no increased post op care
Increased pin torque on 12 wks
One nonunion

86. Conclusions: Remember Kaufer’s Variables
Uncontrolled factors
Fracture Geometry
Bone Quality
Surgeon controlled factors
Quality of Reduction
Implant Placement
Implant Selection

87. Position screw centrally and very deep (TAD≤20mm)
Conclusions:
Implants have different traits-choose wisely
Position screw centrally and very deep (TAD≤20mm)

88. Conclusions: Things change Healing is no longer “success”
Deformity & function matter
Perioperative insult counts

90. Audience Response Questions! (save 5-8 minutes for these)

91. 81 y.o. female slipped & fell 3 part IT fx
Discuss:
Did the surgeon do a good job?
Yes or No
Post-op X-rays

92. Did the surgeon do a good job?
Yes No
Answer before advancing.

93. Now, consider specifically:
A.The reduction is satisfactory B. The TAD (screw position) is OK C. Both are satisfactory D. Neither are satisfactory …Choose Best Answer

94. 6 months
3months

95. Post op

96. The TAD was acceptable but the reduction was grossly short

97. Did the surgeon do a good job?
Yes No

99. 27yo jogger struck by car, closed, isolated injury

100. 27yo jogger struck by car
I’d reduce & fix with: A. 95° blade B. DCS plate C. “Recon” Nail D. DHS E. Intramedullary hip screw (PFN, TFN, IMHS, GAMMA)

102. A. The reduction is satisfactory B. The TAD is satisfactory C
A.The reduction is satisfactory B. The TAD is satisfactory C. Both are satisfactory D. Neither are satisfactory

103. *

104. Progressive pain 11-14 weeks (varus + plate is rarely good)

105. I’d Bonegraft & revise with: A. 95° blade B. DCS plate C
I’d Bonegraft & revise with: A. 95° blade B. DCS plate C. “Recon” Nail D. DHS E. IMHS F Other

106. 95° DCS + autoBG

107. 71 yo renal txplnt pt c CHF
What to do??

108. If my patient, I would use:
1. Hip screw and sideplate
2. Hip screw and IM nail (TFN)
3. Reconstruction Nail (2 proximal medullary-cephalic screws)
4. Blade Plate
5. Other

109. percutaneous reduction

110. Uneventful Healing, WBAT
6wks 12wks

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