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Intertrochanteric Fractures

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Unanswered clinical issues and audience questions
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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:

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
Un
con
tro
lled

 Pre-injury physical & cognitive status
 Ability to visit a friend or go shopping

Su
Co rge
ntr on
oll
ed
!

 Presence of home companion

 Postoperative ambulation
 Postoperative complications
(Cedar, Thorngren, Parker, others)

130.000 IT & will double by 2050…  4-12% fixation failure Even when surgery is “successful”:  1-2 units PRBC transfused  3-5+ days length of stay We must do better!! .A public heath care cri$i$: Fx / year in U.S.

JBJS(B) ‘93  General versus spinal anaesthesia? Buck’s traction of no value (RCT) Randomized. prospective trials (RCTs): no difference Davis. Valentin. of comfort Anderson. Anaesth & IntCare ‘81. avoid night surgery JBJS(A) ‘95  Maintain extremity in positionZuckerman.Preoperative Management the evidence suggests:  “Tune up” correctable comorbidities  Operate within 48°. Br J Anaesth ‘86 .

Supplement 4 December 2010 .Comprehensive Management excellent evidence based single source: Osteoporosis International “Preoperative Guidelines and Care Models for Hip Fractures” Volume 21.

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

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

Factors Influencing Construct Strength: ncontrolled factors Bone Quality Fracture Geometry ontrolled 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 .

31 AO / OTA .

Uncontrolled factor: Fracture geometry Stable Unstable .

Uncontrolled factor: Fracture geometry AO/OTA31A3: The highly unstable “pertrochanteric” fractures! .

Not at all like a geriatric fracture . cancellous bone throughout the proximal femur.Uncontrolled factor: Bone quality A 33 year old pt with intertrochanteric fracture following a fall from heightNote the dense.

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

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

JOT ‘97  Clinical Factors in 2010 influence use delivery.Uncontrolled factor: Bone quality Can / Should we strengthen the bone-implant interface?  PMMA 12 to 37% increase load to failure Choueka. Koval et al. et al. stiffer Moore. ActaOrthop ‘96  CPPC 15% increased yield strength. et al. complications must be considered  Hydroxy-apatite (HA) coated screws Reduced cut out in poorly positioned fixation Moroni. cost. CORR ‘04 ... Goldstein.

s‘80e CORR 1980 th . CORR N eKauffer.Factors Influencing Construct Strength: Uncontrolled factors   Fracture Geometry Bone Quality Surgeon controlled factors    Quality of Reduction Implant Placement Implant Selection t e g !! to ght d ri e e Kaufer.

et al. et al. JBJS (B) ‘93 RCT Gargan. JBJS (B) ‘94  Limited role for reduction & fixation of trochanteric fragments (biology vs stability) Surgical goal: Biplanar. anatomic alignment proximal & shaft fragments Mild valgus reduction for  instability to offset shortening of .Surgeon controlled factor Fracture Reduction When employing sliding hip screws…  No role for displacement osteotomy RCT Desjardins.

etc.Surgeon controlled factor Fracture Reduction  Discuss sequence of closed reduction steps  Consider adjuncts to fracture reduction Crutch… elevator… joystick…. Lever technique– read this article: .

Surgeon controlled factor of Fracture Reduction 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 .

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

and in the middle of the femoral neck intersects the joint .Surgeon controlled factor: Implant position Apex of the femoral head Defined as the point where a line parallel to.

Surgeon controlled factor: Implant position Screw Position: TAD Xap Tip-Apex Distance = Xlat Xap + Xlat .

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

Lindskog.Surgeon controlled factor: Implant position Risk of Cut Out Probability of Cut Out Increasing TAD -> Baumgaertner. Keggi JBJS (A) ‘95 . Curtin.

Keggi JBJS (A) ‘95 .6  Unstable Fracture p = 0. Lindskog.002  Increasing TAD p = 0.6  Screw Zone p = 0.Surgeon controlled factor: Implant position Logistic Regression Analysis Multivariate (dependent variable:Cut Out)  Reduction Quality p = 0.0002 Baumgaertner. Curtin.03  Increasing Age p = 0.

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  .

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

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

GAMMA The First to Reach the Market .

Gamma Clinical Results Advantages : ± Complications : +++ Bridle JBJS(B) '91 Boriani Orthopaedics '91 Lindsey Trauma '91 Halder JBJS(B) '92 Williams Injury '92 LeungJBJS(B) '92 Aune ActOrthopScan '94 .

CHS 1996 Meta-analysis of ten randomized trials • Shaft fractures: Gamma 3  x CHS (p < 0.001) • Required Re-ops: Gamma 2  x CHS (p < 0.01) • IM fixation may be superior for inter/subtroch extension & reverse obliquity fractures • “ CHS is a forgiving implant when used by inexperienced surgeons. International Orthopaedics '96 . the Gamma nail is not” MJParker.Surgeon controlled factor: Implant selection Gamma Nail vs. Parker.

Schemitsch et al.Gamma nails revisited (risk of shaft fracture…. JOT 2009 No more increased risk with nails .) Bhandari.

Lindskog. Curtin. wide functional outcomes Baumgaertner. IMHS vs CHS. CORR ‘98 . 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.Surgeon controlled factor: Implant selection IM Fixation: Clinical Results RCT.

05) Hardy. less blood loss  Improved post-op mobility @ 1 & 3 months *  Improved community ambulation @ 6 & 12 months *  45% less sliding. et.Surgeon controlled factor: Implant selection IM Fixation: Clinical Results Well analyzed RCT. N = 100  Longer surgery. LLD* (* p < 0. al JBJS(A) ‘98 . IMHS vs CHS.

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

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 .Key point It is not the reduced lever arm that offers the clinically significant mechanical advantage.

The nail substitutes for the incompetent posteromedial cortex .

31.A33 2 weeks 7 months The nail substitutes for the incompetent lateral cortex .

et al JBJS(A) ‘07 Iatrogenic. 3% overall) A2 to A3 fx! .2&3 fxs 22% failure rate (vs.CHS: Unique risk of failure Palm. intraoperative lateral wall fracture 31% risk in A2.

N = 108  Improved post-op mobility (4 months)*  less sliding. CORR ‘02 RCT.05)  Pajarinen. shaft medialization* Ahrengart. N = 46 5° in neck shaft angle @ 6 wks (all) shaft medialization @ 4mo * Pajarinen. Int Orth ‘04 RCT. IMscrew vs CHS. JBJS(B) ‘05 . IMscrew vs CHS. shaft medialization* (* p < 0. IMscrew vs CHS. N = 436  less sliding.Surgeon controlled factor: Implant selection IM Fixation: Selected Clinical Results RCT.

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. Trauma ‘03 Bong. Trauma ‘04 . blood loss ? complications. JOT '98 Su. length of rehab Madsen.

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

fractures @ Mayo: overall 30% failure rate  Poor Implant Position: 80% failure  Implant Type: Compression Hip Screw: 95° blade / DCS: IMHipScrew: 56% failure (9/16) 20% failure (5/25) 0% failure (0/3) Haidukewych. JBJS(A) 2001 .Surgeon controlled factor: Implant selection Reverse Oblique Fractures Retrospective review of 49 consecutive R/ob.

.

Hoffmeyer JBJS(A) 2002 .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 All Significantly Blood tx Failure rate reduced! Major reoperations Sadowski.

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

.

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

.

JOT 2000 52 consecutive fractures.Surgeon controlled factor: Implant selection Long Gamma Nail for IT-ST Fxs Barquet. 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 .

3) 347 articles reviewed: 10 relevant. 5 RCTs* “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 Kregor. et al (Evidence Based Working Group) JOT ‘05 .Surgeon controlled factor: Implant selection Unstable Pertroch Fractures (OTA31A.

CHS 31 AO / OTA .

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 ???? 31 AO / OTA NAIL .

et al.Surgeon controlled factor: Implant selection IM Fixation vs. one distal interlock prn rotational instability (rarely used)  . all got 130° x 11mm nail.3)  --excludes the fxs KNOWN to do best with IM Surgeons Only 4. JOT 4/05 All ambulatory. no ASA Vs Fractures Excluded inter/subtrochs fractures (31A. Closed reduction. CHS Randomized/prospective trial of 210 pts. all experienced  Technique All got spinals. Patients  Utrilla. percutaneous fixation All overreamed 2mm.

et al. CHS Randomized/prospective trial of 210 pts.Surgeon controlled factor: Implant selection IM Fixation vs. JOT 4/05 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 . Results • • • • • Utrilla.

JBJS(A) 2010 No difference: • Transfusions • Hospital stay  Re-ops  Mobility  Residence .

However….  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? .

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 .

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 .

but adequate .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.

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! (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 of nail insertion) at time .

JBJS(A)’98  X-rays post-op. et. then 6 & 12 weeks .Postoperative Management  Allow all patients to WBAT  Patients “self regulate” force on hip  No increased rate of failure Koval. al.

Epilogue: intertrochs (Questions without good answers) .

Unanswered questions Where’s the evidence?? .

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

JBJS(A)‘98 One or two needed ? Nobody knows! .Which nail design is best ?? Proximal diameter? Nail Length? Distal interlocking? Proximal screw ? Sleeve or no sleeve? Loch & Kyle.

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! .

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

JOT ‘05 Only relevant for plate fixation? But… the “Z effect”  7/70. 10% Werner-Tutschku.Small Screws protect lateral wall from fx Gotfried. Unfall ’02  5/45 11% Tyllianakis Acta Orthop Belgica ‘04 . CORR ‘04 Im.

Long vs.short nails? Thigh pain from short. locked nails? Periprosthetic fracture: Still an issue? Anterior cortex perforation with long nails? 6% impinge/ 2% fx Robinson. JBJS(A) 05 Cost/ benefit? -Nobody knows- .

fewer txfusions. no comps Moroni.Just when you think you know whats best. JBJS(A) 4/05 . et al.- Don’t forget Ex-Fix! ? RCT n=40 Exfix +HA vs DHS Faster ops.

Patients Moroni. et al. no increased post op care Increased pin torque on removal @ 12 wks One nonunion  .Ex-fix (HApins) vs DHS Randomized/prospective trial of 40 pts. similar final function No pin site infxs. JBJS(A) 4/05 65yo+ walking women with osteoporosis  Results Faster operations with Fewer transfusions Less post op pain.

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

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)

female slipped & fell 3 part IT fx Discuss: Did the surgeon do a good job? Yes or No Post-op X-rays .o.81 y.

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

Both are satisfactory D. consider specifically: A.Now. Neither are satisfactory …Choose Best Answer . The TAD (screw position) is OK C.The reduction is satisfactory B.

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. isolated injury . closed.

95° blade B. Intramedullary hip .27yo jogger struck by car I’d reduce & fix with: A. DHS E. “Recon” Nail D. DCS plate C.

.

Both are satisfactory D. The TAD is satisfactory C.The reduction is satisfactory B. Neither are satisfactory .A.

* * .

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

DHS E. DCS plate C. “Recon” Nail D.I’d Bonegraft & revise with: A. IMHS F Other . 95° blade B.

95° DCS + autoBG .

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

Other . I would use: 1.If my patient. Hip screw and sideplate 2. Hip screw and IM nail (TFN) 3. Blade Plate 5. Reconstruction Nail (2 proximal medullary-cephalic screws) 4.

percutaneous reduction .

Uneventful Healing. WBAT 6wks 12wks .

please send an e-mail to ota@aaos.org E-mail OTA about Questions/Comments Return to  Lower Extremity  Index .If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides.