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

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

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)

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!!

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

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

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

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

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

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

Stable Unstable AO / OTA 31

Uncontrolled factor: Fracture geometry Stable Unstable

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!

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

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

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

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

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

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

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:

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

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

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!

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

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

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

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

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

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 = 0.0002 Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95

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

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

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

The First to Reach the Market GAMMA The First to Reach the Market

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

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

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

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

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

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

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

The nail substitutes for the incompetent posteromedial cortex

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

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

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 angle @ 6 wks (all) shaft medialization @ 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

Surgeon controlled factor: Implant selection CHS Improvements: 1975-2010 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

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

Reverse Oblique Fractures Surgeon controlled factor: Implant selection Reverse Oblique Fractures Retrospective review of 49 consecutive R/ob. fractures @ 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

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

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

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

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

Reduction Aids

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

CHS AO / OTA 31

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

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

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

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)

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

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

However…. This is gold? Grossly underpowered (beta error) 300-500/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.

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

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)

Technical Tips

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

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

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

Guide Pin Insertion

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

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

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)

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

Epilogue: intertrochs (Questions without good answers)

Unanswered questions Where’s the evidence??

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

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!

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 strength @ failure Clinical significance?? Nobody knows!

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

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

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-

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 ?

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 removal @ 12 wks One nonunion

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

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

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

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

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

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

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

6 months 3months

Post op

The TAD was acceptable but the reduction was grossly short

Did the surgeon do a good job? Yes No

27yo jogger struck by car, closed, isolated injury

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)

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

*

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

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

95° DCS + autoBG

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

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

percutaneous reduction

Uneventful Healing, WBAT 6wks 12wks

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