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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)