Presentation on theme: "Intertrochanteric Fractures"— Presentation transcript:
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 lectureTHIS 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 usefulMichael R. Baumgaertner, MDOriginal Authors: Steve Morgan, MD; March 2004;New Author: Michael R. Baumgaertner, MD; Revised January 2007Revised December 2010
2 Lecture Objectives Review: Introduce: Suggest: Understand & Optimize Principles of treatmentUnderstand & OptimizeVariables influencing patientand fracture outcomeIntroduce:Recent Evidence-based medSuggest:Surgical Tips to avoid common problems
3 Hip Fracture PATIENT Outcome Predictors UncontrolledSurgeon Controlled!Pre-injury physical & cognitive statusAbility to visit a friend or go shoppingPresence of home companionPostoperative ambulationPostoperative 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 failure1-2 units PRBC transfused3-5+ days length of stayEven when surgery is “successful”:We must do better!!
5 Preoperative Management the evidence suggests: “Tune up” correctable comorbiditiesOperate within 48°; avoid night surgeryMaintain extremity in position of comfortGeneral versus spinal anaesthesia?Zuckerman, JBJS(A) ‘95Buck’s traction of no value (RCT)Anderson, JBJS(B) ‘93Randomized, prospective trials (RCTs): no differenceDavis, 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 201015 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 posteriorlyMuscle attachments determine deformity
8 Plain Films Radiographs AP pelvis Cross-table lateral ER Traction view when in any doubt!!Plain FilmsAP pelvisCross-table lateral
9 Factors Influencing Construct Strength: Uncontrolled factorsBone QualityFracture GeometryControlled factorsQuality of ReductionImplant PlacementImplant SelectionKaufer, CORR 1980This lecture will examine each factor
10 Uncontrolled factor: Fracture geometry “STABILITY”The ability of the reduced fracture to support physiologic loadingFracture Stability relates not only to the # of fragments but the fracture plane as well
13 AO/OTA31A3: The highly unstable “pertrochanteric” fractures! Uncontrolled factor: Fracture geometryThis 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 qualityImplants must be placed where the remaining trabeculae reside!
17 Can / Should we strengthen the bone-implant interface? Uncontrolled factor: Bone qualityCan / Should we strengthen the bone-implant interface?PMMA12 to 37% increase load to failureChoueka, Koval et al., ActaOrthop ‘96CPPC15% increased yield strength, stifferMoore, Goldstein, et al., JOT ‘97Elder, Goulet, et al., JOT ‘00Clinical Factors in 2010 influence usedelivery, cost, complications must be consideredMultiple 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 screwsReduced cut out in poorly positioned fixationMoroni, et al. CORR ‘04
18 Factors Influencing Construct Strength: Uncontrolled factorsFracture GeometryBone QualitySurgeon controlled factorsQuality of ReductionImplant PlacementImplant SelectionNeed to get these right!!Kaufer, CORR ‘80Kauffer, CORR 1980
19 When employing sliding hip screws… Surgeon controlled factorFracture ReductionWhen employing sliding hip screws…No role for displacement osteotomyLimited role for reduction & fixation of trochanteric fragments (biology vs stability)Surgical goal: Biplanar, anatomic alignment of proximal & shaft fragmentsMild valgus reduction for hinstability to offset shorteningRCT Gargan, et al. JBJS (B) ‘94RCT Desjardins, et al. JBJS (B) ‘93
20 Fracture Reduction Discuss sequence of closed reduction steps Surgeon controlled factorFracture ReductionDiscuss sequence of closed reduction stepsConsider 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 positionApex of the femoral headDefined 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 positionScrew Position: TADTip-Apex Distance=Xap+lat
28 Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95 Surgeon controlled factor: Implant positionProbability of Cut OutRisk of Cut OutIncreasing TAD ->Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
29 Logistic Regression Analysis Surgeon controlled factor: Implant positionLogistic Regression AnalysisMultivariate (dependent variable:Cut Out)Reduction Quality p = 0.6Screw Zone p = 0.6Unstable Fracture p = 0.03Increasing Age p = 0.002Increasing TAD p =Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
30 Optimal Screw Placement Surgeon controlled factor: Implant positionOptimal Screw PlacementDead CenterandVery Deep(TAD<25mm)Best boneNo moment arm for rotational instabilityMaximum slideValidates reduction
31 What’s the big deal? IM vs Plate Fixation Surgeon controlled factor: Implant selectionWhat’s the big deal?IM vs Plate Fixation
32 IM Fixation Recent History: Theoretical Biologic Advantages Percutaneous ProcedureEBL, Muscle stripping, Complications, Rehab time?Surgical wounds s/p ORIF with IM device
33 The First to Reach the Market GAMMAThe First to Reach the Market
35 Gamma Nail vs. CHS Gamma Nail vs. CHS Surgeon controlled factor: Implant selectionGamma Nail vs. CHSGamma Nail vs. CHS1996 Meta-analysis of ten randomized trials•Shaft fractures: Gamma 3•x CHS (p < 0.001)x CHS (p < 0.001)••Required Re-ops: Gamma 2Required Re-ops: Gamma 2x CHS (p < 0.01)x CHS (p < 0.01)••IM fixation may be superior for inter/subtrochIM fixation may be superior for inter/subtrochextension & reverse obliquity fracturesextension & reverse obliquity fractures••““CHS is a forgiving implant when used byCHS is a forgiving implant when used byinexperienced surgeons, the Gamma nail is not”inexperienced surgeons, the Gamma nail is not”MJParker, International Orthopaedics '96Parker, International Orthopaedics '96
36 No more increased risk with nails Gamma nails revisited (risk of shaft fracture….) Bhandari, Schemitsch et al. JOT 2009No more increased risk with nails
37 IM Fixation: Clinical Results Surgeon controlled factor: Implant selectionIM Fixation: Clinical ResultsRCT, IMHS vs CHS, N = 135No difference for stable fxsFaster & less bloody for unstable fxsFewer IM complications than GammaWeaknesses:No stratification of unstable fracturesLearning curve issuesNo anatomic outcomes, wide functional outcomesBaumgaertner, Curtin, Lindskog, CORR ‘98
38 IM Fixation: Clinical Results Surgeon controlled factor: Implant selectionIM Fixation: Clinical ResultsWell analyzed RCT, IMHS vs CHS, N = 100Longer surgery, less blood lossImproved 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
40 Key pointIt 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 weeks2 weeks7 months7 monthsThe nail substitutes for the incompetent lateral cortex
43 Iatrogenic, intraoperative lateral wall fracture CHS: Unique risk of failurePalm, et al JBJS(A) ‘07Iatrogenic, intraoperative lateral wall fracture31% 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 selectionIM Fixation: Selected Clinical ResultsRCT, IMscrew vs CHS, N = 436less sliding, shaft medialization*Ahrengart, CORR ‘02RCT, IMscrew vs CHS, N = 465° in neck shaft 6 wks (all)shaft 4mo *Pajarinen, Int Orth ‘04Improved post-op mobility (4 months)*less sliding, shaft medialization*RCT, IMscrew vs CHS, N = 108(* p < 0.05)Pajarinen, JBJS(B) ‘05
54 Long Gamma Nail for IT-ST Fxs Surgeon controlled factor: Implant selectionLong Gamma Nail for IT-ST FxsBarquet, JOT 200052 consecutive fractures; 43 with 1 year f/u100% union81 minutes, 370cc EBLThe authors describe the key percutaneous reduction techniques that lead to successful management of these difficult fractures
56 Unstable Pertroch Fractures (OTA31A.3) Surgeon controlled factor: Implant selectionUnstable Pertroch Fractures (OTA31A.3)“Evidence-based bottom line:”Unacceptable failure rates with CHSBetter results with 95° devicesBest results with I M devices*Best “functional outcome” not known347 articles reviewed: 10 relevant; 5 RCTs*Kregor, et al (Evidence Based Working Group) JOT ‘05
59 Surgeon controlled factor: Implant selection There is no data to support nailing over sideplate fixation for A1 fractures
60 CHS????AO / OTA31No 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 fracturesNAIL
61 Surgeon controlled factor: Implant selection IM Fixation vs. CHS Randomized/prospective trial of 210 pts. Utrilla, et al. JOT 4/05PatientsAll ambulatory, no ASA VsFracturesExcluded inter/subtrochs fractures (31A.3)--excludes the fxs KNOWN to do best with IMSurgeonsOnly 4, all experiencedTechniqueAll got spinals, Closed reduction, percutaneous fixationAll 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 4/05ResultsSkin to skin time unchangedFewer blood transfusions needed with IMBetter walking ability in Unstable fractures with IMNo shaft fxsFewer re-ops needed in IM group (1 vs 4)ConclusionIM fixation or CHS for stable fxsUnlocked IM for most Unstable fxs
63 SHS remains the “Gold Standard” JBJS(A) 2010SHS remains the “Gold Standard”No difference:Re-opsMobilityResidenceTransfusionsHospital stay
64 However…. This is gold? Grossly underpowered (beta error) /arm neededAny patient eligible (age 42-99)Used Long NailsOutcome measures perfunctoryNo X-rays32% mortality21% phone /proxy onlyThis 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 selectionIM Hip Screws Author’s OpinionData supports use for unstable fracturesRCTs document improved anatomy and early functionIatrogenic problems decreased with current designs and techniqueIndicated only for the geriatric fractureThese 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 selectionIM Hip Screw: Contraindicationsyoung patients (excess bone removal)basal neck fxs (iatrogenic displacement)stable fractures requiring open reduction (inefficient)stable fractures with very narrow canals (inefficient)
68 Patient Set-up Position for nailing: Hip Adducted Unobstructed AP & lateral imagingFracture 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 txnFx: flexed & addWell leg extended & abductedLateral Xray: a little different, but adequate
79 Which nail design is best ?? Proximal diameter?Nail Length?Distal interlocking?Proximal screw ?Sleeve or no sleeve? Loch & Kyle, JBJS(A)‘98One or two needed ?Nobody knows!
80 Proximal fixation: 1 or 2 screws? Kubiak, JOT ‘04 IMHS vs Trigen in vitro (cadaveric) testingResults:No difference in fx sliding or collapseNo difference in rigidity or stabilityTrigen with higher ultimate failureClinical significance??Nobody knows!
81 Small Screws protect lateral wall Only relevant for plate fixation? Gotfried, CORR ‘04Im, JOT ‘05
82 But… the “Z effect”7/70, 10% Werner-Tutschku, Unfall ’025/45 11% Tyllianakis Acta Orthop Belgica ‘04Small Screws protect lateral wall from fx Only relevant for plate fixation?Gotfried, CORR ‘04Im, JOT ‘05
83 Long vs.short nails? -Nobody knows- 6% impinge/ 2% fx Robinson, JBJS(A) 05Long 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 DHSFaster ops, fewer txfusions, no compsMoroni, 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) 4/05Patients65yo+ walking women with osteoporosisResultsFaster operations with Fewer transfusionsLess post op pain, similar final functionNo pin site infxs, no increased post op careIncreased pin torque on 12 wksOne nonunion
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