Hip Fracture: A Surgeon’s Perspective
Mellick J Chehade
PhD, MBBS, FRACS, FAOrthA
Orthopaedic Trauma Surgeon
University of Adelaide
Royal Adelaide Hospital
Declaration of Interest
I declare that in the past three years I have:
• held shares in: Nil • received royalties from: Nil • done consulting work for: Nil • given paid presentations for:Nil • received institutional support from:
Stryker South Pacific Zimmer
•other AO Foundation
OTC Foundation
Signed:
Outline
Background
Decision to operate
Timing
Implant options and biomechanics
Surgical exposures
Rehabilitation decisions
Follow-up
Outcome measures and Audit
Background
Osteopenia complicates both fracture treatment and healing Internal fixation compromised
Poor screw purchase
Increased risk of screw pull out
Increased risk of non-union
Screw-Bone Interface?
Osteoporosis – Challenge
Changes in cortical bone
Decreased thickness
Increase of bone diameter to maintain bending stiffness
CT cross sections of the femur
Changes in cortical bone
Increased haversian canal areas (lacunae formation)
Increased weakness and predisposition to
low-energy fractures
Changes in cancellous bone
Less and thinner trabeculae with fewer, often broken
interconnections
Courtesy of Ralph Müller
Swiss Federal Institute of Technology, Zürich
Young, normal lumbar spine Osteoporotic lumbar spine
Changes in cortical and cancellous bone
78-year-old male, normal bone 72-year-old male, osteoporotic bone
Changes in cancellous bone
Reduced cutout resistance and bone voids
Decision to operate
Need to carefully consider and plan for
options early - this includes
NON OPERATIVE MANAGEMENT
Informed Consent
Medical condition – fitness for surgery
Cognition
Rehabilitation potential
Advance directives
Family
Palliative options-facilities
End of Life Issues
Advance directives
Treatment dilemmas
Family conflicts
Costly (US 27% final year)
Inhumane
Timing
Ideally ASAP
Realistically < 36 hours
“daylight”
end of day after admission
Issues
Medical Optimisation
Anaesthetist requirements (ECHO)
Theatre / Surgeon availability
Getting Consent
“Quality Systems” vs “KPI’s” (clinician vs administrator)
Implant options and
biomechanics
Changes in cortical bone
Decreased thickness
Less “working length” of implants
Courtesy of Stephan Perren
Implant characteristics—biomechanics
• Conventional screws
• Screws loaded in tension
• Plate-bone friction
• Compression at fracture site
Locking head screws (LHS)
• Screws loaded in shear
• No compression of fracture
Clinical advantages in osteoporosis
• LHS cannot be over-tightened
• Higher resistance against bending forces
• No secondary screw loosening
• Suitable for minimal invasive procedures
Specific implant characteristics—blades
Increased bone-implant interface by blades instead of
screws—contact area of +53%
Specific implant characteristics—augmentation
Increased bone-implant
interface by augmentation
around the inserted screws
Hip fractures Trochanteric (extra-capsular) vs Neck (Intra-capsular)
https://www2.aofoundation.org/wps/portal/surgery?showPage=diagnosis&bone=Femur&segment=Proximal
Trochanteric Anastomosis
anastomotic ring of arteries
found in the trochanteric fossa
and around the neck of the
femur.
Formed by the union of
branches from:
1) medial circumflex femoral
artery.
2) ascending branch of the
lateral circumflex femoral artery.
3) inferior gluteal artery.
4) superior gluteal artery.
1 2
3
4
Arteries & nerves of gluteal region
Hip Fractures
Trochanteric fractures
Extracapsular (well vascularized)
Region distal to the neck between the trochanters
Calcar femorale
Posteromedial cortex
Important muscular insertions
Trochanteric Fractures
Pertrochanteric
stable
Pertrochanteric
unstable
Intertrochanteric
reverse oblique
Nails and Plates
Basic IM Nailing Workshop -City Month #, 201#
Basic IM Nailing Workshop -City Month #, 201#
DHS
Rarely “anatomical”
(Rao et al, 162 unstable #’s –
90% medial displacement
Frohlich & Benko, 182 #’s –
47% > 1cm shortening
Associated with pain on W/B
Hip Fractures Femoral neck fractures
Intracapsular location
Vascular Supply
Medial and lateral circumflex vessels anastamose at the base of the neck
blood supply predominately from ascending arteries (90%)
Artery of ligamentum teres (10%)
1,2 Compression Screw
3,4 Austin Moore
Garden Classification
Arthroplasty Options Hemi vs Total
https://aoanjrr.dmac.adelaide.edu.au/
Surgical exposures
Approaches (abductors/stability v exposure)
Posterior
Lateral
Anterior
Surgical experience
Equipment
Available options
Hoppenfeld surgical exposures 2nd edition
Lateral approach
59
86 yo – living in nursing home
post op
6/12 post op
60
6/52 post surgery 1 year post surgery
PROTECTED WEIGHT-BEARING:
SAFETY
OR SCIENCE FICTION?
Protecting (Fooling) Who?
269% max
211% max
156% max
187% max
99% max
187% max
98% max
Peak loads (% Body Weight)
Normal
Walking 2.5 – 3 x
Sitting/ Standing 2 – 2.5 x
In bed
Sitting up in bed 1-5 – 2 x
Pelvic tilt/pull up 1.5-1.8 x
FWB with aids 0.8 -1.8 x
Stumbling
Rehabilitation
‘…the realisation of optimal function despite residual disability or the development of a person to the fullest physical,
psychological, social, vocational and educational potential consistent with his or her physiological
or anatomical impairment and environmental limitations…”
Follow up
Extremely Variable
Private vs Public
Independent living vs Nursing Home
Remote location
Patients magically find their own way
back when needed
By Whom?
GP
Orthopaedic Surgeon
Geriatrician
Rehab Physician
Case coordinator (nurse?) - Multi_D links
Nobody
RAH Remote/Virtual Clinic
Research assistant Nurse?
Community Xrays
Teleradiology
Asynchronous Orthopaedic Review
Customised (Patient Centred Responses)
Hip fracture Outcomes From Virtual Clinic
Includes:
Baseline data
Mortality
Complications
Surgical data
Patient important outcome factors:
Residence
Pain
Mobility
Function
Hip Pain
Percent of Patients Reporting No Hip Pain
0
10
20
30
40
50
60
70
80
90
100
DHS Short Gamma nail Long Gamma nail
Comparisonof 6 month dataacross devicesp=0.189Chi-square test
6 weeks
3 months
6 months
Pre-injury
% o
f p
ati
en
ts a
ss
es
se
d
Percent Return of Function
% Return of Function After Hip Fracture(median IQR)
0
25
50
75
100
DHS Short Gamma nail Long Gamma nail
Comparisonof 6 month dataacross devicesp=0.074Kruskal-Wallis test
6 weeks
3 months
6 months
% r
etu
rn o
f fu
nc
tio
n
Return to Home
Percent of Patients Living at Home at Time of InjuryWho Are Living at Home at Follow-up
0
10
20
30
40
50
60
70
80
90
100
DHS Short Gamma nail Long Gamma nail
Comparisonof 6 month dataacross devicesp=0.123Chi-square test
3 months
6 months
% o
f p
ati
en
ts a
ss
es
se
d
Percent Early Deaths
29%
18.6%
14.3%
10.5%
0
5
10
15
20
25
30
35
Within 6 months Within 12 months
Perc
en
t o
f h
om
e r
esid
en
ts
Male
Female
1 yr mortality for community ambulating males matches all patient
mortality (29%) including palliative cases and nursing home residents
Percent Deaths Within 1 year Home Vs Nursing Home
57%
29%
43%
14.3%
0
10
20
30
40
50
60
Own home Nursing home
Perc
en
t o
f h
om
e r
esid
en
ts
Male
Female
Biggest gender difference in mortality is in those living at home at the time
of injury (community ambulators)
Summary
Challenging
Optimising biomechanics to minimise immobility and maximise function
Holistic orthopaedic surgeon
Bone is connected to a human being
Good outcomes require successful management at EACH & EVERY STEP of
the “patient journey”
COLLABORATION
DATA COLLECTION
EDUCATION
The Australian Musculoskeletal Education Collaboration: AMSEC
www.amsec.org.au