Slide 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 lecture Michael R. Baumgaertner, MD Original Authors: Steve Morgan, MD; March 2004; New Author: Michael R. Baumgaertner, MD; Revised January 2007 Revised December 2010 Slide 2 Lecture Objectives Review: F Principles of treatment Understand & Optimize F Variables influencing patient and fracture outcome Introduce: F Recent Evidence- based med Suggest: F Surgical Tips to avoid common problems Review: F Principles of treatment Understand & Optimize F Variables influencing patient and fracture outcome Introduce: F Recent Evidence- based med Suggest: F Surgical Tips to avoid common problems Slide 3 Hip Fracture PATIENT Outcome Predictors 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) 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) Uncontrolled Surgeon Controlled! Slide 4 A public heath care cri $ i $ : 130,000 IT Fx / year in U.S. & will double by 2050 We must do better!! 1-2 units PRBC transfused 3-5+ days length of stay 1-2 units PRBC transfused 3-5+ days length of stay Even when surgery is successful: 4-12% fixation failure Slide 5 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? Tune up correctable comorbidities Operate within 48; avoid night surgery Maintain extremity in position of comfort General versus spinal anaesthesia? Anderson, JBJS(B) 93 Zuckerman, JBJS(A) 95 Davis, Anaesth & IntCare 81; Valentin, Br J Anaesth 86 Bucks traction of no value (RCT) Randomized, prospective trials (RCTs): no difference Slide 6 Comprehensive Management excellent evidence based single source: Osteoporosis International Preoperative Guidelines and Care Models for Hip Fractures Volume 21, Supplement 4 December 2010 Osteoporosis International Preoperative Guidelines and Care Models for Hip Fractures Volume 21, Supplement 4 December 2010 Slide 7 Intertrochanteric Femur Anatomic considerations Capsule inserts on IT line anteriorly, but at midcervical level posteriorly Muscle attachments determine deformity Capsule inserts on IT line anteriorly, but at midcervical level posteriorly Muscle attachments determine deformity Slide 8 l ER Traction view when in any doubt!! l ER Traction view when in any doubt!! Radiographs Plain Films l AP pelvis l Cross-table lateral Plain Films l AP pelvis l Cross-table lateral Slide 9 Uncontrolled factors Bone Quality Fracture Geometry Controlled factors Quality of Reduction Implant Placement Implant Selection Uncontrolled factors Bone Quality Fracture Geometry Controlled factors Quality of Reduction Implant Placement Implant Selection Kaufer, CORR 1980 Factors Influencing Construct Strength: This lecture will examine each factor Slide 10 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 Uncontrolled factor: Fracture geometry Slide 11 AO / OTA 31 Slide 12 StableUnstable Uncontrolled factor: Fracture geometry Slide 13 AO/OTA31A3: The highly unstable pertrochanteric fractures! Uncontrolled factor: Fracture geometry Slide 14 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 Slide 15 83 yo white woman with unstable intertrochanteric fracture: Note the marked loss of trabeculae Uncontrolled factor: Bone quality Slide 16 Implants must be placed where the remaining trabeculae reside! Slide 17 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 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 Hydroxy-apatite (HA) coated screws Reduced cut out in poorly positioned fixation Moroni, et al. CORR 04 Hydroxy-apatite (HA) coated screws Reduced cut out in poorly positioned fixation Moroni, et al. CORR 04 Uncontrolled factor: Bone quality Slide 18 Kauffer, CORR 1980 Uncontrolled factors l Fracture Geometry l Bone Quality Surgeon controlled factors l Quality of Reduction l Implant Placement l Implant Selection Uncontrolled factors l Fracture Geometry l Bone Quality Surgeon controlled factors l Quality of Reduction l Implant Placement l Implant Selection Kaufer, CORR 80 Factors Influencing Construct Strength: Need to get these right!! Slide 19 Fracture Reduction 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 instability to offset shortening 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 instability to offset shortening When employing sliding hip screws RCT Gargan, et al. JBJS (B) 94 RCT Desjardins, et al. JBJS (B) 93 Surgeon controlled factor Slide 20 Fracture Reduction Discuss sequence of closed reduction steps Consider adjuncts to fracture reduction Crutch elevator joystick. etc. Lever technique read this article: Discuss sequence of closed reduction steps Consider adjuncts to fracture reduction Crutch elevator joystick. etc. Lever technique read this article: Surgeon controlled factor Slide 21 of Fracture Reduction Surgeon controlled factor Double density of medial cortex is evidence of intussuscepted neck into shaft seen on lateral Slide 22 Traction will not reduce this sag but a lever into the fracture will Slide 23 Traction will not reduce this sag but a lever into the fracture will reduce it Slide 24 The AP view before and after lever redution: the medial cortex is restored Fracture Reduction Surgeon controlled factor Slide 25 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 Surgeon controlled factor: Implant position Slide 26 Screw Position: TAD Tip-Apex Distance = X ap + X lat Tip-Apex Distance = X ap + X lat X X X ap X Surgeon controlled factor: Implant position Slide 27 Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) 95 Slide 28 Probability of Cut Out Increasing TAD -> Risk of Cut Out Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) 95 Surgeon controlled factor: Implant position Slide 29 Logistic Regression Analysis Multivariate (dependent variable:Cut Out) l Reduction Quality p = 0.6 l Screw Zone p = 0.6 l Unstable Fracture p = 0.03 l Increasing Age p = 0.002 l Increasing TAD p = 0.0002 Multivariate (dependent variable:Cut Out) l Reduction Quality p = 0.6 l Screw Zone p = 0.6 l Unstable Fracture p = 0.03 l Increasing Age p = 0.002 l Increasing TAD p = 0.0002 Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) 95 Surgeon controlled factor: Implant position Slide 30 Dead Center and Very Deep (TAD 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) Use at least a 130 nail Varus Corrections Advance nail Increase traction ABDUCT extremity!! (adduction only necessary at time of nail insertion) Slide 75 Allow all patients to WBAT Patients self regulate force on hip No increased rate of failure X-rays post-op, then 6 & 12 weeks Allow all patients to WBAT Patients self regulate force on hip No increased rate of failure X-rays post-op, then 6 & 12 weeks Postoperative Management Koval, et. al,JBJS(A)98 Slide 76 Epilogue: intertrochs (Questions without good answers) Slide 77 Wheres the evidence?? Unanswered questions Slide 78 Minimally invasive PLATE fixation ?? 2 hole DHS Bolhofner Dipaola PCCP Gotfried 2 hole DHS Bolhofner Dipaola PCCP Gotfried Slide 79 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! Slide 80 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?? 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! Slide 81 Small Screws protect lateral wall Only relevant for plate fixation? Gotfried, CORR 04 Im, JOT 05 Slide 82 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 Slide 83 Thigh pain from short, locked nails? Periprosthetic fracture: Still an issue? Anterior cortex perforation with long nails? Cost/ benefit? -Nobody knows- 6% impinge/ 2% fx Robinson, JBJS(A) 05 Long vs.short nails? Slide 84 Just when you think you know whats best- - Dont forget Ex-Fix! RCT n=40 Exfix +HA vs DHS Faster ops, fewer txfusions, no comps Moroni, et al. JBJS(A) 4/05 ? Slide 85 Ex-fix (HApins) vs DHS Randomized/prospective trial of 40 pts. Moroni, et al. JBJS(A) 4/05 Patients l 65yo+ walking women with osteoporosis Results l Faster operations with Fewer transfusions l Less post op pain, similar final function l No pin site infxs, no increased post op care l Increased pin torque on removal @ 12 wks l One nonunion Patients l 65yo+ walking women with osteoporosis Results l Faster operations with Fewer transfusions l Less post op pain, similar final function l No pin site infxs, no increased post op care l Increased pin torque on removal @ 12 wks l One nonunion Slide 86 Conclusions: Remember Kaufers Variables Uncontrolled factors Fracture Geometry Bone Quality Surgeon controlled factors Quality of Reduction Implant Placement Implant Selection Uncontrolled factors Fracture Geometry Bone Quality Surgeon controlled factors Quality of Reduction Implant Placement Implant Selection Slide 87 Position screw centrally and very deep (TAD20mm) Implants have different traits-choose wisely Conclusions: Slide 88 Things change Conclusions: Healing is no longer success Deformity & function matter Perioperative insult counts Healing is no longer success Deformity & function matter Perioperative insult counts Slide 89 Slide 90 Audience Response Questions! (save 5-8 minutes for these) Slide 91 81 y.o. female slipped & fell 3 part IT fx Post-op X-rays Discuss: Did the surgeon do a good job? Did the surgeon do a good job? Yes or No Slide 92 Did the surgeon do a good job? Yes No Yes No Answer before advancing. Slide 93 A.The reduction is satisfactory B. The TAD (screw position) is OK C. Both are satisfactory D. Neither are satisfactory Choose Best Answer Now, consider specifically : Slide 94 3months 6 months Slide 95 Post op Slide 96 The TAD was acceptable but the reduction was grossly short Slide 97 Did the surgeon do a good job? Yes No Yes No Slide 98 Slide 99 27yo jogger struck by car, closed, isolated injury Slide 100 27yo jogger struck by car Id reduce & fix with: A. 95 blade B. DCS plate C. Recon Nail D. DHS E. Intramedullary hip screw (PFN, TFN, IMHS, GAMMA) Slide 101 Slide 102 A.The reduction is satisfactory B. The TAD is satisfactory C. Both are satisfactory D. Neither are satisfactory Slide 103 * * Slide 104 Progressive pain 11-14 weeks (varus + plate is rarely good) Slide 105 Id Bonegraft & revise with: A. 95 blade B. DCS plate C. Recon Nail D. DHS E. IMHS F Other Slide 106 95 DCS + autoBG Slide 107 71 yo renal txplnt pt c CHF What to do?? Slide 108 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 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 Slide 109 percutaneous reduction Slide 110 Uneventful Healing, WBAT 6wks12wks Slide 111 Return to Lower Extremity Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.orgota@aaos.org