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SLIDING HIP SCREW FIXATION FOR PROXIMAL FEMUR FRACTURES: AN ANALYSIS OF THE PREDICTIVE FACTORS OF FAILURE Dr Tao Shan Lim MBBS Grad Dip Surg Anat Mr Karl.

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Presentation on theme: "SLIDING HIP SCREW FIXATION FOR PROXIMAL FEMUR FRACTURES: AN ANALYSIS OF THE PREDICTIVE FACTORS OF FAILURE Dr Tao Shan Lim MBBS Grad Dip Surg Anat Mr Karl."— Presentation transcript:

1 SLIDING HIP SCREW FIXATION FOR PROXIMAL FEMUR FRACTURES: AN ANALYSIS OF THE PREDICTIVE FACTORS OF FAILURE Dr Tao Shan Lim MBBS Grad Dip Surg Anat Mr Karl Stoffel MD Dr Rochelle Nicholls PhD Dr Bianca Billik MBBS Fremantle Orthopaedic Unit Fremantle Hospital Western Australia

2 The Sliding Hip Screw Trochanteric region #’s Maximises healing potential Elderly / co-morbidities

3 Failure 8 – 23% Bone quality Fragment geometry Reduction Implant placement Kaufer, Clinical Orthopaedics 1980, Jan-Feb:53–61. Dodds & Baumgaertner, Current Opinion in Orthopedics 2004, Feb:12-17

4 Baumgaertner, 1995 Tip – Apex Distance > 25mm 19 failures in 198 fractures (9.6%) –16 cut out Baumgaertner et al, J Bone Joint Surg Am Jul;77(7):

5 Baumgaertner, 1995 Tip – Apex Distance > 25mm 19 failures in 198 fractures (9.6%) –16 cut out 5 different devices –142 sliding hip screw (3 manufacturers) –56 intramedullary nail (2 manufacturers) Baumgaertner et al, J Bone Joint Surg Am Jul;77(7):

6 Study Aims Local experience of use –Dynamic Hip Screw –Exclusive use since March 2001 Identify failures Identify predictive factors

7 Study Design Retrospective radiological audit 731 cases 701 patients 2002 – 2004

8 Inclusion Criteria New adult proximal femur fracture Adequate imaging –Preoperative –Implant

9 Methods Theatre database Ortho techs PACSRevision –Cause

10 PACS Picture Archiving Computer System Fremantle Hospital –2001 Sir Charles Gairdner Hospital –2004 Royal Perth Hospital –2004

11 Fracture Classification AO / Muller Evan’s Müller et al; Manual of internal fixation: techniques recommended by the AO-ASIF group, ed 3, Berlin, 1991, Springer-Verlag

12 Fracture Classification AO / Muller Evan’s Evan E. J Bone Joint Surg 1949;31B:190–203

13 X-rays 1. Reduction Alignment AP Normal or slight valgus Alignment Lateral Less than 20 degrees tilt of femoral head

14 X-rays 1. Reduction Displacement Less than 5mm displacement of any bone fragment

15 X-rays 1. Reduction 2. Tip – Apex Distance Baumgaertner et al, J Bone Joint Surg Am Jul;77(7):

16 X-rays 1. Reduction 2. Tip – Apex Distance 3. Position of screw in femoral head Cleveland et al, J Bone Joint Surg Am Dec;41-A:

17 Exclusion Criteria Not a fracture –1 case (myeloma) Inadequate imaging –11 cases

18 Demographics 387 Females, 120 Males –Female : Male 2.79 : 1 Mean age 80.9 years –Range 15.0 – –SD 13.0

19 Age

20 ASA Score

21 Radiological Follow Up Intraoperative only 25.3% Postoperative X-ray within 2 weeks 33.8% X-ray between 2 weeks and 3 months 17.9% X-ray after 3 months 23.0%

22 Surgeon Consultant10.7% 41 min Fellow1.8% 43 min Training registrar 50.6% 39 min Service registrar 36.9% 50 min

23 Surgeon Consultant10.7% 41 min Fellow1.8% 43 min Training registrar 50.6% 39 min Service registrar 36.9% 50 min P < 0.001

24 Fracture Region 22.4% 76.3% 1.2% 22.4% 76.3% 1.2% N = 164 N = 407 N = 9 N = 164 N = 407 N = 9

25 Trochanter vs Neck Age(years)ASA Contralateral #NOF % %

26 AO / Muller Classification % % % N = 9

27 AO / Muller Classification % % % N = 9

28 AO / Muller Classification % % % N = 9

29 Evan’s Classification 73.7% N = % N = 149

30 Reduction Good % Acceptable % Poor %

31 Cleveland Zone

32 Tip – Apex Distance Mean 20mm –Range 5 to 44 –SD 6.1 Stable ≈ unstable –20 vs 22 mm

33 Tip – Apex Distance

34 Failures 14 revisions - 2.5% –In 567 cases! 10 cut out –Superior breach of femoral head 4 failures of plate screws –“Reverse cut out”

35 Failures 14 revisions - 2.5% –In 567 cases! 10 cut out –Superior breach of femoral head 4 failures of plate screws –“Reverse cut out”

36 Failures 14 revisions - 2.5% –In 567 cases! 10 cut out –Superior breach of femoral head 4 failures of plate screws –“Reverse cut out”

37 Cut Out - TAD P < 0.001

38 Cut Out - TAD Cut Out TAD < 25 TAD ≥ 25 Yes010 No Total0%7.7%

39 Cut Out Evan’s Unstable –10 of 10 Displacement > 4mm –10 of 10 Varus reduction –8 of 10

40 Cut Out – Cleveland Zone

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42

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44 Bivariate Regression RankVariable P value 1 Tip-Apex Distance 1.86 x Evan’s Unstable 9.10 x Poor Reduction 5.25 x Inferior Posterior Hip Screw 9.85 x Superior Anterior Hip Screw 3.11 x 10 -5

45 Multivariate Regression RankVariable P value 1 Tip-Apex Distance 1.58 x Evan’s Unstable 4.30 x Poor Reduction 6.21 x 10 -1

46 Failure Rate of 2.5%? Choice of implant –Less unstable Quality of results –Mean TAD 20mm (Baumgaertner 25mm) Computerised PACS –Statewide tertiary catchment

47 Failure Rate of 2.5%?

48 Choice of implant –Less unstable Quality of results –Mean TAD 20mm (Baumgaertner 25mm) Computerised PACS –Statewide tertiary catchment

49 Failure Rate of 2.5%? Choice of implant –Less unstable Quality of results –Mean TAD 20mm (Baumgaertner 25mm) Computerised PACS –Statewide tertiary catchment

50 Study Weaknesses Level IV evidence Observer bias Loss of failures to the private sector ? X-rays on clinical need

51 Summary Accurate reflection of experience Captures all complications and revisions in Western Australian tertiary centres

52

53 Acknowledgements Synthes Australia –Ben Fraser FH, SCGH, RPH Orthopaedic Technicians –Particularly Steve and Ken from Fremantle My wife May –Data entry!

54 Insurance Status InsuranceN% HO % VA8010.9% PI385.2% MV141.9% OV60.8% WC20.3%

55 Plate Length LengthN% 2 hole 152.6% 4 hole % 5 hole 162.8% 6 hole 111.9% 8 hole 20.4% 12 hole 10.2%

56 Plate Angle AngleN% 130 deg % 135 deg % 140 deg 468.1% 145 deg 101.8% 150 deg 30.5%

57 DHS Extras ImplantN% Trochanteric Side Plate 122.1% Antirotation Screw 71.2%


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