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Fractures of the femur AO Principles Course Leeds 2005 Module : Principles of operative management of common fractures David L Shaw.

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Presentation on theme: "Fractures of the femur AO Principles Course Leeds 2005 Module : Principles of operative management of common fractures David L Shaw."— Presentation transcript:

1 Fractures of the femur AO Principles Course Leeds 2005 Module : Principles of operative management of common fractures David L Shaw

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3 Fractures of the Femoral Shaft(AO 3.2) Why should I fix the #? Why should I fix the #? How should I fix it ? How should I fix it ? What complications can I expect ? What complications can I expect ?

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5 Paediatric fractures See article See article Gallows Gallows Hip Spica Hip Spica Traction Traction

6 Why fix the # Save life Save life Poly trauma Poly trauma Save limb Save limb Preserve function Preserve function Stabilisation with immediate rehabilitation Stabilisation with immediate rehabilitation

7 Choose a method ? Plating Plating Rigid fixation Abs stability Rigid fixation Abs stability LISS LISS LCP LCP Ext fixn Ext fixn IM Nail IM Nail Consider absolute vs relative stabilityConsider absolute vs relative stability Consider soft tissues and scarsConsider soft tissues and scars Consider facilities and equipmentConsider facilities and equipment

8 Choose a method 2 Patient factors Patient factors Facilities, time and polytrauma Facilities, time and polytrauma Damage control orthopaedics Damage control orthopaedics

9 Get me a nail!

10 Rods & Nails When is a nail not a nail When is a nail not a nail Hollow – Slotted – Solid Hollow – Slotted – Solid Why nails fail Why nails fail Effects of Reaming Effects of Reaming

11 Bones & Nails Hollow structures Hollow bones for strength Hollow bones for strength Early nails were hollow & needed 3 point fixation Early nails were hollow & needed 3 point fixation

12 Kuntcher - Clover leaf nail 3 point fixation 3 point fixation Inserted open so no guide wire required Inserted open so no guide wire required

13 GK & AO – Slotted hollow nail Allowed guide wire insertion Allowed guide wire insertion Flat sheet manufacture Flat sheet manufacture

14 Reaming to increase the contact area

15 Lets talk about stiffness

16 Bending Stiffness Second Moment of Inertia (I) Tube Tube I=(Ro 4 – Ri 4 ) * ¶/4 I=(Ro 4 – Ri 4 ) * ¶/4 Radius cubed Radius cubed

17 Hollow structures are relatively strong for the volume of material Hollow structures are relatively strong for the volume of material For a given increase in radius torsional and bending stiffness go up to the fourth power For a given increase in radius torsional and bending stiffness go up to the fourth power Torsional stiffness roughly 2x inc vs bending as radius Torsional stiffness roughly 2x inc vs bending as radius At physiological loads torsional deformation more clinically evident At physiological loads torsional deformation more clinically evident

18 Slotted nails especially are weak in torsion

19 The advantage of Unreamed Solid Ti nails are strong enough at diameters small enough to be inserted without reaming Solid Ti nails are strong enough at diameters small enough to be inserted without reaming Not possible with SS nails Not possible with SS nails Expensive Expensive The advantage of Solid

20 You be the Judge

21 For unreamed Healing Healing 170 # 170 # Equivalent healing time (19/52) Equivalent healing time (19/52) 55mins quicker 55mins quicker = delayed unions = delayed unions Reynders Injury 2000 Reynders Injury 2000

22 General Results General Results 164# retrospective series 164# retrospective series 93% union rate with UFN 93% union rate with UFN AO type C healed at 6.2mo (ave) AO type C healed at 6.2mo (ave) UFN healing rates comparable with historical standards UFN healing rates comparable with historical standards Herscovici JOT 2000 Herscovici JOT 2000 For unreamed

23 Intramedullary pressure Intramedullary pressure Clinical trial 38 pts Clinical trial 38 pts 5x increased pressure in reamed group 5x increased pressure in reamed group Pressure correlated with fat extravasation Pressure correlated with fat extravasation Berger JOT 1997 Berger JOT 1997

24 Poly Trauma Poly Trauma Femur # in polytrauma pts managed by; Femur # in polytrauma pts managed by; Early Total Care Early Total Care Intermediate Stabilisation Intermediate Stabilisation Damage Control Surgery Damage Control Surgery A significant reduction in the incidence of complications was found..regardless of the type of fixation A significant reduction in the incidence of complications was found..regardless of the type of fixation Garapati & Krettek J of T 2002 Garapati & Krettek J of T 2002 For unreamed

25 Against unreamed method Healing Healing 147# 147# 6 weeks longer to heal 6 weeks longer to heal Giannoudis Injury 1997 Giannoudis Injury # 172# 4 weeks longer to heal 4 weeks longer to heal More technical complications More technical complications Tornetta JOT 2000 Tornetta JOT 2000

26 Against unreamed method Stimulation of the inflammatory system Stimulation of the inflammatory system IL6, CD11b, s-ICAM-1, E-selectin & elastase IL6, CD11b, s-ICAM-1, E-selectin & elastase Reamed vs Unreamed Reamed vs Unreamed Evidence of a second hit to the immune system Evidence of a second hit to the immune system No difference reamed vs unreamed No difference reamed vs unreamed Giannoudis JBJS(B) 1999 Giannoudis JBJS(B) 1999 If you dont ream you still get a second hit to the immune system If you dont ream you still get a second hit to the immune system

27 Against unreamed method Complications Complications 100 randomised pts 100 randomised pts 2x iatrogenic comminution in unreamed 2x iatrogenic comminution in unreamed Reaming was required in the unreamed group in 3 Reaming was required in the unreamed group in 3 Shepherd J Orthop Trauma 2001 Shepherd J Orthop Trauma 2001

28 For unreamed Quicker Quicker Simpler Simpler Less equipment Less equipment Equivalent healing rate Equivalent healing rate Less fat embolus Less fat embolus Less H-O Less H-O Lower immune hit Lower immune hit

29 For reamed Faster union Faster union Fewer implant related complications Fewer implant related complications Lung injury not directly & only caused by reaming Lung injury not directly & only caused by reaming Second hit not specifically caused by reaming Second hit not specifically caused by reaming

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31 Its all about technique

32 Reaming is a technique Solid nails are implants

33 Solid nail ? Who would put a 9mm nail in this pt! Who would put a 9mm nail in this pt!

34 Summary & Verdict Reaming is a technique Reaming is a technique Solid vs Slotted vs Cannulated Solid vs Slotted vs Cannulated is a design / manufacturing process is a design / manufacturing process

35 I always do reamed nails

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41 Summary Chose the smallest nail which is strong enough for the patient and his/her injury Chose the smallest nail which is strong enough for the patient and his/her injury Ream if necessary to put the appropriate size of nail in for the patient & injury Ream if necessary to put the appropriate size of nail in for the patient & injury Dont confuse implants with technique Dont confuse implants with technique

42 Other peoples complications General complicationsGeneral complications Specific # related comlpicationsSpecific # related comlpications MalunionMalunion

43 Cambells Operative Orthopaedics Malunions after closed treatment are the rule Malunions after closed treatment are the rule

44 Malrotation > 10 degrees in 8-19% of fractures > 10 degrees in 8-19% of fractures JBJS 75 (B) JBJS 75 (B) JBJS 66 (A) JBJS 66 (A)

45 Cambells Operative Orthopaedics..become significant only if they result in..become significant only if they result in shortening of more than 2.5 cm shortening of more than 2.5 cm angulated more than 10 degrees angulated more than 10 degrees internally or externally rotated to the point that the knee cannot be aligned with forward motion during gait. internally or externally rotated to the point that the knee cannot be aligned with forward motion during gait.

46 ? How much rotation ? External rotation less well compensated External rotation less well compensated than internal 15 degree limit 15 degree limit Based on functional assessments and FPA Based on functional assessments and FPA Nijmegen group: Injury Nijmegen group: Injury

47 Malunion > 2.5 cm shortening > 2.5 cm shortening > 10° angular deformity > 10° angular deformity >15° rotation deformity >15° rotation deformity

48 Malunion > 2.5 cm shortening > 2.5 cm shortening > 10° angular deformity > 10° angular deformity Rotation that the pt can see ! Rotation that the pt can see !

49 Fractures of the Femoral Shaft(AO 3.2) Why should I fix the #? Why should I fix the #? Damage control Damage control Restore function Restore function How should I fix it ? How should I fix it ? For the fracture / for the patient For the fracture / for the patient What complications can I expect What complications can I expect Length, Rotation the pt can see Length, Rotation the pt can see

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