How to Fix a Prox Femur Fx

How to fix a How to fix a proximal femoral proximal femoral fracture?fracture?

Vilmos Vécsei, MUV, Dept. for Trauma Surgery, Austria

Trochanteric fx.-features:Age: 7.+ 8. decade, Female/Male: 3:1,

Fall to the hip, Comorbidities,

Reduced ambulation

capacity, typical diplacement

tendency Surgery is

indicated, Bone quality impaired,

Danger of losing of personal

independency,…

►Osteoporosis

► Female sex

►Caucasian race

►Slightly built individuals

► Limited physical activity.

UKW

Hip fractures in Europe

~ ~ 360 mill. 360 mill. populationpopulation

20020000

400.000400.000 100.000100.000 €€

Actual aspects: Epidemiology

20502050

750.000750.000 200.000200.000 €€

Trochanteric Fractures: Epidemiology

V. VécseiV. Vécsei

USA 2.000.000 patients

Annual overall costs

~ ~ 16 Billionen 16 Billionen $$

USAUSA

Per - / Subtrochanteric FracturesPer - / Subtrochanteric Fractures

V. Vécsei

70% of all femoral fx.s are situated in the proximal third(Femoral neck, Trochanterregion)

Under the most frequent fractures an the third place –in adults

As a rule good healing tendency

The mortality rate is higher compared to FNF

• trauma is bigger• fracture surface is bigger• soft tissue damage is bigger

70% of all femoral fx.s are situated in the proximal third(Femoral neck, Trochanterregion)

Under the most frequent fractures an the third place –in adults

As a rule good healing tendency

The mortality rate is higher compared to FNF

• trauma is bigger• fracture surface is bigger• soft tissue damage is bigger

EtiologyEtiology

V. Vécsei

Jung patient Older patient

Exceptional

High Energy Trauma

Subtrochanteric > pertrochanteric Fx

Combination with polytrauma

Prognosis depends on the concommitant injuries

Frequent

Low Energy Trauma

Pertrochanteric > subtrochanteric Fx

Multimorbidity

Prognosis depends on the comotbidities

Loss of the inner solidity

Characteristics of trochanteric fractures

Loss of inner resistance leads to varus of Loss of inner resistance leads to varus of the proximal fragment,the proximal fragment,

The load transmission capacity disappears,The load transmission capacity disappears,

Shortening of the leg occures,Shortening of the leg occures,

By excellent tendency to bony healing, By excellent tendency to bony healing, since the blood supply to the bone is not since the blood supply to the bone is not disturbed,disturbed,

AVN occures seldom.AVN occures seldom.

hip [tr] fxhip [tr] fx

major cause of excess mortality - major cause of excess mortality -

morbiditymorbidity

in elderly peoplein elderly people

most tr fx should undergo

anatomical reduction & internal fixation

bone-implant construct stable enough bone-implant construct stable enough

early painless full weight-bearingearly painless full weight-bearing

high health and social service expenditureshigh health and social service expenditures

Therapy - GoalTherapy - Goal

V. Vécsei

Quick surgical treatment, if possible within 6 hours after admissionQuick surgical treatment, if possible within 6 hours after admission

Returne to the former social surrounding

Fast mobilization with reference to the mobility before accident

Avoidance of internal complications

33% Mortality within one year

50% are returning to their former conditions

Osteosynthesis with ambulation by full weight bearing

Osteosynthesis with ambulation by full weight bearing

Early mobilizationEarly mobilization

Atraumatic, gentle, quick surgical OP technicAtraumatic, gentle, quick surgical OP technic

““When there is When there is cortical cortical

instabilityinstabilityon one side of a on one side of a

fx fx as a result of as a result of

cortical overlap cortical overlap or destruction,or destruction,the fx tends to the fx tends to

collapse collapse in the direction in the direction

of such of such instability”instability”

Evans 49Evans 49

Fx.

Insta

bilit

y

““In fx with In fx with reversed reversed obliquityobliquitythere is there is marked marked

tendency tendency toward toward medial medial

displacemendisplacement of the t of the shaftshaft

secondary secondary to to

adductor adductor muscle pull”muscle pull”

Wright 47Wright 47

Fx.

Insta

bily

reverse [oblique] tr fxreverse [oblique] tr fx

often also fx. line

separating GT

medialization

Fx.instability

medial and lateral cortices interrupted

multifragmentary direct [oblique] tr. fxmultifragmentary direct [oblique] tr. fx

medial - posterior cortex interrupted

medial defect varus

posterior defect retroversion, external rotation

medializationGT lateral defect

Fx.instability

instabilityinstability

likelihood of likelihood of

difficulties in achieving accurate fx. difficulties in achieving accurate fx.

reduction,reduction,

loss of reduction after fixationloss of reduction after fixation

most trochanteric fx are most trochanteric fx are unstableunstable

768 / 1024 [75%]768 / 1024 [75%] Chirodian Chirodian 0505

311 / 458 311 / 458 [68%][68%]

Barquet Barquet 03 03

65 / 12265 / 122 [53%][53%] Taeger Taeger 00 00

Levy 92Levy 92

Boyd 49, Evans 49,Boyd 49, Evans 49, Ehalt 50, Hafner 51, Rasmussen 53, Ramadier 56, Ehalt 50, Hafner 51, Rasmussen 53, Ramadier 56, Wade 59, Ottolenghi 64, Decoulx 69,Wade 59, Ottolenghi 64, Decoulx 69, Ender 70, Tronzo 73, Ender 70, Tronzo 73,

Jensen-Michaelsen 75, Deburge 76, Kyle 79, Briot 80, Müller 80, Jensen-Michaelsen 75, Deburge 76, Kyle 79, Briot 80, Müller 80, Müller 90, Moehring 97, Cirotteau 02Müller 90, Moehring 97, Cirotteau 02

numerous proposed classificationsnumerous proposed classifications

AO classificationAO classification

most widely usedmost widely used

A1: Simple (2-fragment) pertrochanteric area fracturesA1.1 Fractures along the intertrochanteric lineA1.2 Fractures through the greater trochanterA1.3 Fractures below the lesser trochanter

Classification: AO

A2: Multifragmentary pertrochanteric fracturesA2.1 With one intermediate fragment A2.2 With 2 intermediate fragmentsA2.3 With more than 2 intermediate fragments

A3: Intertrochanteric fracturesA3.1 Simple, obliqueA3.2 Simple, transverseA3.3 With a medial fragment

Is this classification validIs this classification valid??

is it is it

easy to use on clinical groundseasy to use on clinical grounds??

all inclusive and mutually exclusive?all inclusive and mutually exclusive?

reproducible? reproducible?

[intra- & interobserver agreement][intra- & interobserver agreement]

associated with relevant patient outcomesassociated with relevant patient outcomes

given specific fx. management plans?given specific fx. management plans?

Audigé 02Audigé 02

Henry 98, Newey 93, De Boeck 94,Henry 98, Newey 93, De Boeck 94, Schipper 01, Pervez 02,

Chapman 03Chapman 03

AO classification tr AO classification tr fxfx

with subgroupswith subgroups

poor reproducibilitypoor reproducibility

unacceptable systemunacceptable system

without subgroupswithout subgroups

acceptable validityacceptable validity

acceptable systemacceptable system

osteoporosis low bone mass

deterioration bone microarchitecture

poor poor implant implant

anchorage anchorage in in

bonebone

bon

e f

rag

ilit

y

assessment of osteoporosis prior to surgeryassessment of osteoporosis prior to surgeryessential in predicting fx fixation stabilityessential in predicting fx fixation stability

Singh’s rx grading (VI to I) trabecular patterns proximal femurSingh’s rx grading (VI to I) trabecular patterns proximal femur

low reproducibility – poor correlation with DXA low reproducibility – poor correlation with DXA Kranendonk 72, Khairi 76, Pogrund 79, Pogrund 81, Sartoris 85, Kranendonk 72, Khairi 76, Pogrund 79, Pogrund 81, Sartoris 85,

Hübsch 92, Masud 95, Koot 96, Soontrapa 05Hübsch 92, Masud 95, Koot 96, Soontrapa 05

Singh III or lower - increased incidence of fixation failureSingh III or lower - increased incidence of fixation failure

useful for clinical purposesuseful for clinical purposes

Dequeker 74, Laros 74, Pogrund 81, Horsman 82, Dequeker 74, Laros 74, Pogrund 81, Horsman 82,

Leichter 82, Lips 84, Gluer 94, Sinha 00Leichter 82, Lips 84, Gluer 94, Sinha 00

I II IIII II III

IV V VIIV V VI

AO classification without subgroupsAO classification without subgroups

Singh classification in 2 groups: I-III and IV-VISingh classification in 2 groups: I-III and IV-VI

stablestablestablestable unstableunstableunstableunstable unstableunstableunstableunstable

higher incidence fixation failurehigher incidence fixation failure lower incidence fixation failurelower incidence fixation failure

I II IIII II III IV V VIIV V VI

may provide

valid guidelines

correctly developed surgical treatment

unstable trochanteric fx

““correctly developedcorrectly developed

reduction and current internal fixation techniquesreduction and current internal fixation techniques

reduce fixation failures to 3.6 % in unstable tr fx”reduce fixation failures to 3.6 % in unstable tr fx”

Chirodian 05Chirodian 05

series with similar distribution of

osteoporosis severity and tr fx. classes

significant differences in fixation failures

influencing factors other than

osteoporosis and fx. geometry

surgical treatment

fixationfixation failure in failure in tr fxtr fx

stable fxstable fx 1 - 1 - 9%9%

unstable unstable fxfx

2 - 2 - 26%26%

Kyle 79, Kaufer 80, Jensen 81, Heyse-Moore 83, Rao 83, Caudle 87, Kyle 79, Kaufer 80, Jensen 81, Heyse-Moore 83, Rao 83, Caudle 87, Simpson 89, Clark 90, Davis 90, Laros 90, van der Schilden 90, Simpson 89, Clark 90, Davis 90, Laros 90, van der Schilden 90,

Nungu 91, Leung 92, Barrios 93, Desjardins 93, Radford 93,Nungu 91, Leung 92, Barrios 93, Desjardins 93, Radford 93,Gundle 95, Stappaerts 95, Albareda 96, Buciuto 98, Barquet 97, Gundle 95, Stappaerts 95, Albareda 96, Buciuto 98, Barquet 97,

Watson 98, Lünsjo 00, Taeger 00, Kukla 01, Docquier 02, Banan 02, Watson 98, Lünsjo 00, Taeger 00, Kukla 01, Docquier 02, Banan 02, Barquet 00, Hesse 04, Chirodian 05, Hernández 05Barquet 00, Hesse 04, Chirodian 05, Hernández 05

surgeon - patient’s tr fx.

should define fx. “personality”

[“class”]

osteoporotic fc? which grade?

Fx. stable or unstable? which type of

instability?

should also define patient’s “personality”

biologic age, general condition, life before fx, biologic age, general condition, life before fx,

medical diseases - ASA classificationmedical diseases - ASA classification

HISTORY

L. Böhler connected to the 3 flange-(blade)-nail a „sideplate“ (1940(?))

• Rigid angled implants (Jewett 1941)

• IM splinting (Küntscher

1941)

• Sliding plate system (Pohl 1951)

•Double T-plate (Teubner )

• Gamma Nail (Grosse,Kempf)

• Dynamic Hip Screw (Richards, AO)

Gerhard Küntscher Y – Nagel = Y Nail1940 1962

Complications - Ender-nailing n= 100

nail dislocation distal < 2 cm 30

(30%)

distal > 2 cm 9 (9%)

proximal = 1,5 cm 1 (1%)

cut out 4 (4%)

FN-perforation 2 (2%)

total 46%EnderEnder

Simon-Weidner, 1972Simon-Weidner, 1972

The Gamma Nail 1988

Osteosynthesis

extramedullaryimplants

intramedullaryimplants

sliding

controled fracture impaction

Basic principles

Bending Forces

Basic principles

a

b

V. F. 64y, male – 0 -

?

V. F. 64y, male, - postop. 4 w -

V. F. 64y, male, - postop. 28 w -

Osteosynthesis

Biomechanical investigations

Fatigue limits Gamma-N.: Loading capacity 1,6 kN subtroch . O.: 91440 cycles pertroch. O.: 71810 cycles revers subtroch.: 44200

Fatigue limits DHS: Loading capacity 1,4 kN subtroch . O.: 75800 cycles pertroch. O.: 60240 cycles revers subtroch.: 5000

Mechanical failure:Mechanical failure:

1)shaftfx. at nail tip1)shaftfx. at nail tip 2)nail breakage at the 2)nail breakage at the eye 3)slow cut-outeye 3)slow cut-out

Mechanical failure:Mechanical failure:

1)Femoral head perf. 1)Femoral head perf. 2)breaking off troch. maj. 2)breaking off troch. maj. 3)fx. femur at edge of 3)fx. femur at edge of plate 4)bending of head plate 4)bending of head screwscrew

Kreusch-Brinker R., et al.: „The Gamma Locking Nail“ Einhorn, Reinbek

Biomechanical examination GN, DHS with butress plate (Sowbone, 1 pair cadaver femora)

Friedl W., Clausen J.: Chirurg (2002) 72: 1344 - 1352

Cycles

100.000

Loadalternatin

g

(N)Stat. Max.

Weight bearing capacity

(N)

Deformation

(mm)

DHS

(1x)

4,000

15,800

2,000 Stat. Max.

2,465-3,049

17,3± 2,06max.

GN

(2x)

4,000

100.000

2,000 Stat. Max.

4,230 -5,557

10,73± 4,3313,3

Friedl W., Clausen J.: Chirurg (2002) 72: 1344 - 1352

Biomechanical examination GN, Gamma, PFN (Sowbone, 3 pairs of cadaver femora)

3 specime

n

1000 cycles/ 1000 Nmigration

1000 cycles/ 1500 Nmigration

6000 cycles/ 1000 – 3000 N

GN 0,7 mm

Gamma

1,69 mm

higher 2 rotation

double

PFN 2 mm1 cut out

higher 3 cut out

double

TECHNICAL HINTS

...... Accurate positioning

...... Accurate positioning

.....accurate reduction is the key!!!

.....even if an open reduction is necessary!!!

.... correct entry point

.... anatomy !!!

...correct lag screw/blade

position is crucial...

OP techniqueOP technique

V. Vécsei

Correct positioning on the traction table

Correct positioning on the traction tableClosed reduction in good alignement

Closed reduction in good alignement

Use of 2 image intensifierUse of 2 image intensifier

Correct position / Lenght

Correct position / Lenght

a./p.a./p. axialaxial

HeadcrewHeadcrew

Spiroid bladeSpiroid blade

cranial cranial

caudal

caudal

v dd vCaution!!! Wrong position of implantDisplacement at the fracture

Cut out of the head screw

Comparative clinical studies►DHS vs. Gamma►PFN vs. Gamma►TGN vs. DHS►TGN vs. Ace►PFN vs. TGN►AMBI vs. TGN

vs.PFN►HP, TEP vs. PFN

► If any only slight differences,

► small numbers of participants,

► randomisation questionable,

► differences often caused by surgical pitfalls and failures, than by superiority or inferiority of the implants

DHS vs. Gamma NailDHS (n=15) Gamma Nail (n=43)

Fractures of the femoral shaft

- 4

Deep infection - 1

Reoperation 4 4

Fracture displacement

1 -

Mortality 13.3% 18.6%

Walking alone 33% 29%

Without aids 8% 20%

Overall complications

26% 16%

Saarenpää et al. International Orthopedics 2007;31:65-70

DHS and Gamma Nail

No differences between DHS and Gamma nails regarding operative time, blood loss, wound complications or patient mobility.

Gamma nail had better placement in the femur

Geiger et al.

Cut out rate: DHS 5.8% Gamma Nail 4%

Dynamic hip screw vs. PFN

Pajarinen J. 108 patients prospective - randomized. JBJS 2005

Patient's recovery after operative treatment: (PFN=42, DHS=41)

Restoration of walking ability was achieved more often in the patients treated with PFN (76.2%) compared with those treated with DHS (53.7%)

Compression hip screw vs. Gamma Nail

CHS (n=216) Gamma Nail (n=210)

Cut out of the femoral head

2% 8%

Problems with distal locking

- 14%

Additional fracture perioperatively

2 patients 5 patients

Fracture reduction unsatisfactory

3% 2%

Fracture union 88% 95%

Ahrengart et al. Clinical Orthop Rel. Res. 2002V. VécseiV. Vécsei

bone fragility & fx. bone fragility & fx.

instabilityinstabilityadversely influence strength of bone-implant adversely influence strength of bone-implant

constructconstruct

facilitate “fixation failure”facilitate “fixation failure”varus displacement,varus displacement, retroversion, medialization,medialization, cut out,cut out,

collapse,collapse, pull off side plate, implant failure pull off side plate, implant failure … …

Criteria for implant selectionCriteria for implant selection

V. Vécsei

Weight bearing-stabilityWeight bearing-stability

Acceptable anchorage osteoporotic bone

Acceptable anchorage osteoporotic bone

Protection of bone vascularity Protection of bone vascularity

Possibility of dynamization (implant+fracture)Possibility of dynamization (implant+fracture)

Simple implantation technique

Sadowski C et al: J Bone Joint Surg 84: 372-381 (2002)

August 1992 - February

1998

one level I trauma centre

1000 consecutive cases

839 unstable fractures

78 trauma surgeons involved

average pt´s age: 81.2 yrs

Prospective study:Prospective study:

intra- and postoperative intra- and postoperative

complicationscomplications

learning curve of one departmentlearning curve of one department

prognostic factorsprognostic factors

Analysis

IOP: intraoperative problems

misdrilling

shaft fractures

open reduction

rotational deformity

Analysis

POP: postoperative problems

cutting out of lag screw

hematoma, DVT

shaft fracture

non-union, implant failure

Fracture classification

31A1 31A2 31A332A, B

n:161 n:741 n:86 n:12 16,1% 74,1% 8,6% 1,2%

Intraoperative (IOP), early (POPearly ) and late problems (POPlate) overall

and with respect to G1 and G2

Overall IOP POPearly POPlate

Misdrilling 34 34 - -

femoral shaft fracture 16 5 6 5

open reduction 5 5 - -

Compl. due to targeting device 12 12 - -

significant diastasis 3 3 - -

rotational deformity >20° 3 3 - -

cutting out of hip screw 21 - 17 4

revision of hematoma 5 - 5 -

superficial infection 3 - 3 0

deep wound infection 17 - 14 3

deep vein thrombosis 7 - 7 -

non-union + nail breakage 1 - - 1

overall percentage 12.7% 6.2% 5.2% 1.3%

G 1 (patients 1-500) 19.1% 11.0% 7.2% 0.9%

G 2 (patients 501-1000) 6.3% 1.4% 3.2% 1.7%

rate of intraoperative

complications (n : 63)

G 1: 11%

G 2: 1.4%

intraoperative problems (n :

63 ))

highly significant risk ratio of

0.5 (p=0.0001) in the

incidence of IOP in relation to

increasing experience

the patients´ risk of sustaining

an IOP was reduced by 50%

each year

Prognostic factors such as

age, ASA-score, associated

injuries or earlier injuries to the

contralateral hip had no

influence on the frequency of

intraoperative complications

postoperative complications (n :

67)

significant decrease (p = 0.001)

in group G2 (5%) compared to

group G1 (8.4%)

early postoperative

complications (5.2%)

significant effects of surgical

experience (p=0.0042), and

ASA-score (p=0.0036)

cutting out of hip screw

(n : 17)

revision due to hematoma

(n : 5)

superficial wound

infection (n : 3)

deep wound infection (n : 14)

deep vein thrombosis (n : 7)

early postop. shaft fractures (n : 3)

late postoperative complications (1.3%)

femoral shaft fractures (n : 5)

cutting out of hips screw (n : 4)

deep wound infections (n : 3)

negative correlation between

age and risk for late POP

risk for POPlate decreased 6.2%

per additional decade

no significant influence of

surgical experience and ASA

score for POPlate

Complications in comparison

early complicationsearly complications

V. Vécsei

Gamma-NailGamma-Nail PFNPFN

Infections 4 4Serom 21 19Hematoma 13 17Fx. of the trochanter major 19 5Re-Operations 1 4

Herrera A et al: Int Orthop 26: 365-369 (2002)

5858 4949

n = 250n = 250 1997 – 2000 / Ø 78,9 J1997 – 2000 / Ø 78,9 J

Late complicationsLate complications

V. Vécsei

Herrera A et al: Int Orthop 26: 365-369 (2002)

3030 3030

n = 250n = 250 1997 – 2000 / Ø 78,9 J1997 – 2000 / Ø 78,9 J

Gamma-Nagel

Gamma-Nagel

PFNAPFNA

Cut out5 1

Sec. Varus displacement (>10%) 2 9„Pain in the muscle“ 7 4Calcification - tip of trochanter 8 6Migration of head screw 4 10Diaphyseal fractures 4 0

Intraop. Shaft fracture

1,2 (0-3.3)

2,6 1,0(1-17)

Head perforation

2,3

Wound healing dis. 6,0 4,0

Postop. Shaft fracture

2,2 1,4

Failure of locking

9,7 0,3

Infection 1,2 2,2

Cut out 3,2 2,6-9,8

3,7 5,8

Non-union 5,0 12,0

Joint dislocation 12,0

Mortality <1 y 18,6 21,4 13,3 34,2

Complication (%) Gamma

PFN GN DHS HP

How to avoid complicationsHow to avoid complications

V. Vécsei

Correct implant placementCorrect implant placement

Correct lenght of Plate- a. ScrewsCorrect lenght of Plate- a. Screws

correct implant selection following fx. configuration

correct implant selection following fx. configuration

After care related to nature of fracture and bony quality (to be adapted)

After care related to nature of fracture and bony quality (to be adapted)

Prosthesis

Complications: THR vs PFN

Geiger F. Arch.Orthop.Trauma Surg 2007

THR PFNDislocation 12%Cutting out, non - union

9.8%

Implantation time

115 84

Mortality 34.2% 21.4%

Suggestions

Provides good bone stock for THR

Place Lag Screw distally

Use intramedullary implants

Osteosynthesis whenever possible

Indication for primary THR only in severe OA with

joint stiffness

„Since we use total hip arthroplasty only in

patients of good physical shape and with severe

osteoarthritis we did not see any dislocations“

Geiger F. Arch.Orthop.Trauma Surg 2007

E.E. 66y, f., - 0 -

E.E. 66y, m., - op. 0 d -

E.E. 66y, f., -5d -

E.E. 66y. f., - 10d -

E.E. 66y, f., - 2.op. 12d -

►Stable fractures: Gliding headscrew combined with a plate – dynamic contstruct to avoid head perforation.

►Unstable fractures: are preferably treaten by IMHN; two screw devices help to counteract rotational movements of the proximal fragment, but weaken the construct; single load carrier need addenda to control rotational changes of the head fragment

Results

Absence of medial support

=

Defect

Long Gamma Nail

Gamma - Nail

Medialization of the head screw

Cut out mechanism

cut out

P. Ch. 90y, female, - 0 d -

P. Ch. 90y, f., - 2 d -

P. Ch. 90y, female

03.03. 07.04. 27.04.

24.02. 03.03. 07.04. 12.05.

P. Ch. 90y, female – the cut out the cut out mechanismmechanism

P. Ch. 90y. f., - 9d -

P. Ch. 90y, female – postop. 44d -

P. Ch. 90y, female, - postop 60 d -

P. Ch. 90y, female – postop. 75 d -

Complications - Fi-nail n = 203(Budapest)

ccut-outut-out 3%3%

implant related compl. totalimplant related compl. total 4,4%4,4%

Greitbauer : 2,1% (1900) 2003 Kollmar : 2,6% (764) 2003

Spitaler: 4% (100) 2004 Boldin: 4% (50) 2003

Cut out numbers (lit.):

M.M., f, 94 y3 we p. OP

fracture of the shaft

Failure of the target device + double locking.

Double locking has been left in 1992 – only in exceptional cases rectified.

M.P, m

6 we p. OP6 we p. OP 3 mo p. 3 mo p. OPIIOPII

Spontaneous fracture of the shaft

OP IIOP II

C.W., f, 70 y

OP I

OP IVOP II

P.G. ,f., 90 y

OP I

screw and implant breakage

3 mo p. OP I

P.G., f. , 90 y

OP II

screw and implant breakage

OP III

3 mo p. OP II3 mo p. OP II

P.G. f. , 90 y

screw and implant breakage

5 mo p. OP III5 mo p. OP III

P.G. f. , 90 y

OP IV

screw and implant breakage

screw and implant breakage

PFN

Z-Effect

Z.C., 87à, w

rotational discrepancy

rotational discrepancy

Complications - PFN n = 77 (WSP)

migration of the hip screw < 1,5 cm migration of the hip screw < 1,5 cm 4 (5%)4 (5%)

> 2 cm > 2 cm 7 (9%)7 (9%)

cut out cut out 2 (2.6%)2 (2.6%)

Z - effect Z - effect 1 (1,3%)1 (1,3%)

fracture of the shaftfracture of the shaft 2 (2,6%)

totaltotal 20,8%20,8%

• “ “cut out”cut out”

• medializationmedialization

• “ “Z – effect”Z – effect”

• rotational discrepancyrotational discrepancy

• fracture of the shaftfracture of the shaft

• screw / implant breakagescrew / implant breakage

intramedullary implants IMHS

Complications

Gamma 3Gamma 3 PFNAPFNA

spec. osteosynthesisspec. osteosynthesis

V. Vécsei

Medoff Plate

Watson, JT, Moed B, Cramer KE, Karges DE Clin. Orth. Rel. Res., 1998

DHS

(n=91) Medoff (n=69)

cut out 4 (4,4%) 1 (1,5%)

migration of the hip screw 2 (2,2%) 1 (1,5%)

plate failure 3 (3,3%) -

total 9 (9,9%) 2 (3%)

complications - Medoff plate vs DHS

Relevant complications after treatment of an trochanteric fx. with DHS are:

1)Varus-displacement of theproximal head and neck fragment,

2)‘Cut-out’ of the head screw

3)Medialization of the femoral shaft.

Montage of a Trochanteric butress plate can reduce these complications and improves the clicial outcome.

LockingTrochanteric Stabilization Plate (LTSP)– offers lateral butressing.– Reduces excessiv sec. impaction at the fracture, counteracts against medialization of the shaft.– Reduces varus malpositioning

and shortening of the length.– It stabilizis the Trochanter major and restores the function of M. gluteus medius.

Locking

Trochanteric Stabilization Plate (LTSP)

– Easy to adapt to the anatomical requirements– Fixation of the upper Trochanter with locking screws– Lateral butressing– Does not allow exzessive dynamization.– Avilable as steel or titanium amendment– Lenght 130 mm

A Holes with thread for 3,5 mm locking scewsA Holes with thread for 3,5 mm locking scews

B The arms can be shortened as neededB The arms can be shortened as needed

C Hole for the placement of an antirotational screw (6.5 mm cannulated, or simple cancellous screw)

C Hole for the placement of an antirotational screw (6.5 mm cannulated, or simple cancellous screw)

D Two holes to be fitted with corticalis screws which are connecting the DHS plate with the LTSP and femoral shaft

D Two holes to be fitted with corticalis screws which are connecting the DHS plate with the LTSP and femoral shaft

E The second prox. hole has a bigger diameter than the head of a 4,5 mm screw; this ellows the fixation of the DHS plate primary to the femur.

E The second prox. hole has a bigger diameter than the head of a 4,5 mm screw; this ellows the fixation of the DHS plate primary to the femur.

Insertion of the antirotational screw

With the targeting devise cranial and parallel to the head screw.

Hints– Tighten of the antirotational screw and the head screw crosswise to get the maximum possible impaction.– If a spiral blade is in use instead of the calssical head screw a separate antirotational screw is not needed.

Insertion of the locking screws

Fixation of fragment od the trochanter with the help of 3.5 mm locking screwsLCP drill sleeve ist should be inserted into the thread of the hole.The drill bit will be introduced through the sleeve.

Monocortical screws with a lenght between 20 to 25 mm should be employed. The application happens with the help of one by 1.5 Nm torque limited dynamometric screwdriver.The dynamization process of the head screw has priority and must not be limited by to long locking screws.

Fixation of the locking screws

► all included in one aiming device

► various CCD

angles

► static and dynamic distal locking

A new target device

►Gamma ►Gamma 3

A new entry point – valgus angle is eliminated

Curved proximal end of the targeting device – to avoid collision with the „soft tissues“

A new head screw

Attachment to the tartget device

Attachment to the tartget device

A new head set screw

The torsional movement of a short head-neck fragment around the headscrew can occure – to avoid this a spreding U-blade can be put above the headscrew

Secondary dynamization

• New blade design, no lag screw

• one hole for static or dynamic distal locking

• all included in one aimimg device

76y f. – 0 -

- 2 d - -14 w -

....... the new bladenew blade is supposed

to compress the surroundingcancelous bone in the femoral neck duringinsertion .......

before blade insertion after blade insertion

locking prevents blade migration

Complications - PFNA n = 131 “first results“Complications - PFNA n = 131 “first results“

2 lateral migration of the blade (... handling

failure ?)

1 problem locking the blade (... product

failure ?)

1 problem disconnecting the blade (... product

failure?/

handling

failure?)

until now one “cut out“

“not locking the blade“

locking failure

The treatment of pertrochanteric fractures in

Austria

standardised questionnaire of 20 trauma-units

stable fractures

Sliding-nail5%

PFN5%

Gamma-nail10%

DHS80%

treatment of unstable pertrochanteric femur fractures in Austria

Gammanail60%

DHS with or without

trochanteric plate10%

various dynamic nails5%

PFN25%

Hints, Advices and Conclusion

► IMHS devices are in unstable fx.s superior compared to the screw+plates devices,► The complication rate has been diminished,► Further improvements of the results due to techniqual development can be expected,► The operative rules should be followed

carefully.

Osteosynthesis

The reason for failure is always clear to see, but on the other hand success is guaranteed through diligent accuracy“

G. Küntscher (1962)