Intertrochanteric Fractures Presenter: Please look at notes to facilitate your talk—
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Intertrochanteric FracturesPresenter: 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
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Lecture ObjectivesLecture 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
Review: Principles of treatment
Understand & Optimize Variables influencing patient
and fracture outcome
Introduce: Recent Evidence-
based med
Suggest: Surgical Tips to avoid common problems
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Hip Fracture PATIENT Outcome Predictors 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)
Unc
ontr
olle
d
Sur
geon
C
ontr
olle
d!
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A public heath care cri$i$: 130,000 IT Fx / year in U.S.& will double by 2050…
A public heath care cri$i$: 130,000 IT Fx / year in U.S.& will double by 2050…
We must do better!!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”:Even when surgery is “successful”:
4-12% fixation failure 4-12% fixation failure
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Preoperative Managementthe evidence suggests:
Preoperative Managementthe 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) ‘93Anderson, JBJS(B) ‘93
Zuckerman, JBJS(A) ‘95Zuckerman, JBJS(A) ‘95
Davis, Anaesth & IntCare ‘81; Davis, Anaesth & IntCare ‘81; Valentin, Br J Anaesth ‘86Valentin, Br J Anaesth ‘86
Buck’s traction of no value (RCT)Buck’s traction of no value (RCT)
Randomized, prospective trials (RCTs): no differenceRandomized, prospective trials (RCTs): no difference
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Comprehensive Managementexcellent evidence based single source:
Comprehensive Managementexcellent 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
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Intertrochanteric FemurAnatomic considerationsIntertrochanteric 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
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ER Traction view when in any doubt!!
ER Traction view when in any doubt!!
RadiographsRadiographs
Plain FilmsAP pelvisCross-table lateral
Plain FilmsAP pelvisCross-table lateral
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Uncontrolled factors Bone Quality Fracture Geometry
Controlled factorsQuality of ReductionImplant Placement Implant Selection
Uncontrolled factors Bone Quality Fracture Geometry
Controlled factorsQuality of ReductionImplant Placement Implant Selection
Kaufer, CORR 1980Kaufer, CORR 1980
Factors Influencing Construct Strength:
Factors Influencing Construct Strength:
This lecture will examine each factorThis lecture will examine each factor
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“STABILITY”“STABILITY”
The ability of the reduced fracture to support physiologic loading
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
Fracture Stability relates not only to the #
of fragments but the fracture plane as well
Uncontrolled factor: Fracture geometry
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AO / OTA
31
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Stable Stable Unstable Unstable
Uncontrolled factor: Fracture geometry
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AO/OTA31A3: AO/OTA31A3: The highly unstable “pertrochanteric” fractures!The highly unstable “pertrochanteric” fractures!
Uncontrolled factor: Fracture geometry
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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
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83 yo white woman with unstable intertrochanteric fracture:
Note the marked loss of trabeculae
Uncontrolled factor: Bone quality
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Uncontrolled factor: Bone quality
Implants must be placed where the remaining trabeculae reside!
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Can / Should we strengthen the bone-implant interface?
Can / Should we strengthen the bone-implant interface?
PMMA12 to 37% increase load to failure
Choueka, Koval et al., ActaOrthop ‘96
CPPC15% 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
PMMA12 to 37% increase load to failure
Choueka, Koval et al., ActaOrthop ‘96
CPPC15% 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 screwsReduced cut out in poorly positioned fixation
Moroni, et al. CORR ‘04
Uncontrolled factor: Bone quality
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Kauffer, CORR 1980Kauffer, CORR 1980
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
Kaufer, CORR ‘80Kaufer, CORR ‘80
Factors Influencing Construct Strength:
Factors Influencing Construct Strength:
Need to g
et
these
right!!
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Fracture Reduction 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…When employing sliding hip screws…When employing sliding hip screws…When employing sliding hip screws…
RCT Gargan, et al. JBJS (B) ‘94RCT Gargan, et al. JBJS (B) ‘94RCT Desjardins, et al. JBJS (B) ‘93RCT Desjardins, et al. JBJS (B) ‘93
Surgeon controlled factor
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Fracture Reduction 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
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of of Fracture Reduction Fracture Reduction Surgeon controlled factor
Double density of medial cortex is evidence of intussuscepted neck into shaft seen on lateral
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Traction will not reduce this “sag” but a lever into the fracture will
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Traction will not reduce this “sag” but a lever into the fracture will reduce it
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The AP view before and after lever redution: the medial cortex is restored
Fracture Reduction Fracture Reduction Surgeon controlled factor
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Apex of the femoral headApex of the femoral head
Defined as the point where a line parallel to, and in the middle of the femoral neck intersects the joint
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
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Screw Position: TADScrew Position: TAD
Tip-Apex Distance = Xap + Xlat Tip-Apex Distance = Xap + Xlat
XlatXlat
XapXap
Surgeon controlled factor: Implant position
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Surgeon controlled factor: Implant position
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
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Probability of Cut OutProbability of Cut Out
Increasing TAD ->Increasing TAD ->
Ris
k o
f C
ut
Ou
tR
isk
of
Cu
t O
ut
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Surgeon controlled factor: Implant position
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Logistic Regression AnalysisLogistic Regression Analysis
Multivariate (dependent variable:Cut Out)
Reduction Quality p = 0.6
Screw Zone p = 0.6 Unstable Fracture p = 0.03 Increasing Age p = 0.002 Increasing TAD p = 0.0002
Multivariate (dependent variable:Cut Out)
Reduction Quality p = 0.6
Screw Zone p = 0.6 Unstable Fracture p = 0.03 Increasing Age p = 0.002 Increasing TAD p = 0.0002
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Surgeon controlled factor: Implant position
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Dead Center and
Very Deep(TAD<25mm)
Dead Center and
Very Deep(TAD<25mm)
Best bone No moment arm for
rotational instability Maximum slide Validates reduction
Best bone No moment arm for
rotational instability Maximum slide Validates reduction
Optimal Screw Placement Optimal Screw Placement Surgeon controlled factor: Implant position
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What’s the big deal?
What’s the big deal?
IM vs Plate Fixation
IM vs Plate Fixation
Surgeon controlled factor: Implant selection
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Percutaneous Procedure
EBL, Muscle stripping, Complications, Rehab time?
Percutaneous Procedure
EBL, Muscle stripping, Complications, Rehab time?
IM Fixation Recent History:IM Fixation Recent History:Theoretical Theoretical BiologicBiologic Advantages AdvantagesIM Fixation Recent History:IM Fixation Recent History:Theoretical Theoretical BiologicBiologic Advantages Advantages
Surgical wounds s/p ORIF with IM deviceSurgical wounds s/p ORIF with IM deviceSurgical wounds s/p ORIF with IM deviceSurgical wounds s/p ORIF with IM device
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GAMMAGAMMAThe First to Reach The First to Reach
the Marketthe Market
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Gamma Clinical ResultsGamma Clinical Results
Complications : +++ Advantages : Advantages : ±
Complications : +++
Bridle JBJS(B) '91
Boriani Orthopaedics '91
Lindsey Trauma '91
Halder JBJS(B) '92
Bridle JBJS(B) '91
Boriani Orthopaedics '91
Lindsey Trauma '91
Halder JBJS(B) '92
Williams Injury '92
Leung JBJS(B) '92
Aune ActOrthopScan '94
Williams Injury '92
Leung JBJS(B) '92
Aune ActOrthopScan '94
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Gamma Nail vs. CHSGamma Nail vs. CHS19961996 Meta-analysis of ten randomized trials trials
• 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, the Gamma nail is not”
• 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, the Gamma nail is not”
Parker, International Orthopaedics '96MJParker, International Orthopaedics '96
Surgeon controlled factor: Implant selection
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Gamma nails revisitedGamma nails revisited(risk of shaft fracture….)(risk of shaft fracture….)
Bhandari, Schemitsch et al. JOT 2009Bhandari, Schemitsch et al. JOT 2009
Gamma nails revisitedGamma nails revisited(risk of shaft fracture….)(risk of shaft fracture….)
Bhandari, Schemitsch et al. JOT 2009Bhandari, Schemitsch et al. JOT 2009
No more increased risk with nailsNo more increased risk with nails
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IM Fixation: Clinical Results IM Fixation: Clinical Results RCT, IMHS vs CHS, N = 135RCT, IMHS vs CHS, N = 135
Baumgaertner, Curtin, Lindskog, CORR ‘98Baumgaertner, Curtin, Lindskog, CORR ‘98
No difference for stable fxs
Faster & less bloody for unstable fxs
Fewer IM complications than Gamma
Weaknesses:No stratification of unstable fracturesLearning curve issuesNo anatomic outcomes, wide functional outcomes
No difference for stable fxs
Faster & less bloody for unstable fxs
Fewer IM complications than Gamma
Weaknesses:No stratification of unstable fracturesLearning curve issuesNo anatomic outcomes, wide functional outcomes
Surgeon controlled factor: Implant selection
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IM Fixation: Clinical Results IM Fixation: Clinical Results
Longer surgery, less blood loss
Improved post-op mobility
@ 1 & 3 months *
Improved community ambulation
@ 6 & 12 months *
45% less sliding, LLD*
Longer surgery, less blood loss
Improved post-op mobility
@ 1 & 3 months *
Improved community ambulation
@ 6 & 12 months *
45% less sliding, LLD*
Well analyzed RCT, IMHS vs CHS, N = 100Well analyzed RCT, IMHS vs CHS, N = 100
((** p p < 0.05) < 0.05)Hardy, et. al JBJS(A) ‘98Hardy, et. al JBJS(A) ‘98
Surgeon controlled factor: Implant selection
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IM Fixation: Mechanical AdvantagesIM Fixation: Mechanical Advantages
?? !!
Surgeon controlled factor: Implant selection
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Key pointKey point
It is not the reduced lever arm that offers the clinically significant mechanical advantage, 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
It is not the reduced lever arm that offers the clinically significant mechanical advantage, 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
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The nail substitutes for the incompetent posteromedial cortex
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31.A33 31.A33
2 weeks 2 weeks 7 months7 months
The nail substitutes for the incompetent lateral cortex
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CHS: Unique risk of failure
Iatrogenic, intraoperative lateral wall fracture
Iatrogenic, intraoperative lateral wall fracture
Palm, et al JBJS(A) ‘07Palm, et al JBJS(A) ‘07
A2 to A3 fx!A2 to A3 fx!
31% risk in A2.31% risk in A2.2&3 2&3 fxs fxs 22% failure rate22% failure rate
(vs. 3% overall)(vs. 3% overall)
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IM Fixation: Selected Clinical Results IM Fixation: Selected Clinical Results
5° in neck shaft angle @ 6 wks (all)
shaft medialization @ 4mo *
5° in neck shaft angle @ 6 wks (all)
shaft medialization @ 4mo *
RCT, IMscrew vs CHS, N = 46RCT, IMscrew vs CHS, N = 46
(* p(* p < 0.05) < 0.05)
Pajarinen, Int Orth ‘04Pajarinen, Int Orth ‘04
Improved post-op mobility (4 months)* less sliding, shaft medialization*
Improved post-op mobility (4 months)* less sliding, shaft medialization*
RCT, IMscrew vs CHS, N = 108RCT, IMscrew vs CHS, N = 108
Pajarinen, JBJS(B) ‘05Pajarinen, JBJS(B) ‘05
RCT, IMscrew vs CHS, N = 436RCT, IMscrew vs CHS, N = 436
Ahrengart, CORR ‘02Ahrengart, CORR ‘02
less sliding, shaft medialization* less sliding, shaft medialization*
Surgeon controlled factor: Implant selection
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Trochanteric Stabilizing Plate (TSP)plate adjunct to limit shaft medialization
Trochanteric Stabilizing Plate (TSP)plate adjunct to limit shaft medialization
major (≥20mm screw slide) collapse
op time, blood loss
? complications, length of rehab
major (≥20mm screw slide) collapse
op time, blood loss
? complications, length of rehab
Madsen, JOT Madsen, JOT '98'98
Su, Trauma Su, Trauma ‘03‘03Bong, Trauma Bong, Trauma ‘04‘04
CHS Improvements: 1975-2010
Surgeon controlled factor: Implant selection
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Reverse Oblique Fractures
Reverse Oblique Fractures
IM Fixation: Best Indications
Surgeon controlled factor: Implant selection
Intertroch + subtrochanteric
fractures
Intertroch + subtrochanteric
fractures
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Haidukewych, JBJS(A) 2001Haidukewych, JBJS(A) 2001
Retrospective review of 49 consecutive R/ob. fractures @ Mayo: overall 30% failure rate
Poor Implant Position: 80% failure
Implant Type:Compression Hip Screw: 56% failure (9/16)
95° blade / DCS: 20% failure (5/25)
IMHipScrew: 0% failure (0/3)
Retrospective review of 49 consecutive R/ob. fractures @ Mayo: overall 30% failure rate
Poor Implant Position: 80% failure
Implant Type:Compression Hip Screw: 56% failure (9/16)
95° blade / DCS: 20% failure (5/25)
IMHipScrew: 0% failure (0/3)
Reverse Oblique FracturesReverse Oblique Fractures
Surgeon controlled factor: Implant selection
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PFN vs 95° sliding screw plate(DCS)RCT of 39 cases done by Swiss AO surgeons
PFN (IM) vs PlateOpen reductions Op-time Blood tx Failure rate Major reoperations
PFN vs 95° sliding screw plate(DCS)RCT of 39 cases done by Swiss AO surgeons
PFN (IM) vs PlateOpen reductions Op-time Blood tx Failure rate Major reoperations
All Significantly reduced!
Sadowski,Hoffmeyer JBJS(A) 2002Sadowski,Hoffmeyer JBJS(A) 2002
Reverse Oblique FracturesReverse Oblique Fractures
Surgeon controlled factor: Implant selection
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Recovery room control X-ray shows loss of medial support, but nail prevents excessive collapse
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Intertroch/ Intertroch/ subtrochanteric subtrochanteric
fxsfxsGreater mechanical demands,
poorer fracture healing
Surgeon controlled factor: Implant selection
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Long Gamma Nail for IT-ST Fxs
Long Gamma Nail for IT-ST Fxs
Barquet, JOT 2000
52 consecutive fractures; 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
Barquet, JOT 2000
52 consecutive fractures; 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
Surgeon controlled factor: Implant selection
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Reduction AidsReduction Aids
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Unstable Pertroch Fractures (OTA31A.3)
Unstable Pertroch Fractures (OTA31A.3)
“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
“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 Kregor, et al (Evidence Based Working Group) JOT ‘05Working Group) JOT ‘05
347 articles reviewed: 10 relevant; 5 RCTs*347 articles reviewed: 10 relevant; 5 RCTs*
Surgeon controlled factor: Implant selection
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AO / OTA
31
CHS
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Grossly displaced Stable (31A.1) fracture treated with ORIF
Grossly displaced Stable (31A.1) fracture treated with ORIF
Surgeon controlled factor: Implant selection
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There is no data to support nailing over sideplate fixation
for A1 fractures
There is no data to support nailing over sideplate fixation
for A1 fractures
Surgeon controlled factor: Implant selection
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AO / OTA
31
CHS
NAIL
????
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IM Fixation vs. CHSRandomized/prospective trial of 210 pts.
Utrilla, et al. JOT 4/05
IM Fixation vs. CHSRandomized/prospective trial of 210 pts.
Utrilla, et al. JOT 4/05Patients
All ambulatory, no ASA Vs
FracturesExcluded inter/subtrochs fractures (31A.3) --excludes the fxs KNOWN to do best with IM
SurgeonsOnly 4, all experienced
TechniqueAll got spinals, Closed reduction, percutaneous fixationAll overreamed 2mm, all got 130° x 11mm nail, one distal interlock prn rotational instability (rarely used)
Patients All ambulatory, no ASA Vs
FracturesExcluded inter/subtrochs fractures (31A.3) --excludes the fxs KNOWN to do best with IM
SurgeonsOnly 4, all experienced
TechniqueAll got spinals, Closed reduction, percutaneous fixationAll overreamed 2mm, all got 130° x 11mm nail, one distal interlock prn rotational instability (rarely used)
Surgeon controlled factor: Implant selection
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Results• 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• 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
IM Fixation vs. CHSRandomized/prospective trial of 210 pts.
Utrilla, et al. JOT 4/05
IM Fixation vs. CHSRandomized/prospective trial of 210 pts.
Utrilla, et al. JOT 4/05
Surgeon controlled factor: Implant selection
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No difference:No difference: Re-ops Mobility Residence
Re-ops Mobility Residence
• Transfusions
• Hospital stay
• Transfusions
• Hospital stay
JBJS(A) 2010JBJS(A) 2010
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However….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
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?This is gold?
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IM Hip ScrewsAuthor’s Opinion
IM Hip ScrewsAuthor’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
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
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IM Hip Screw: ContraindicationsIM 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)
young patients (excess bone removal)
basal neck fxs (iatrogenic displacement)
stable fractures requiring open reduction
(inefficient)
stable fractures with very narrow canals
(inefficient)
Surgeon controlled factor: Implant selection
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Technical Tips
Technical Tips
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Patient Set-upPatient Set-up
Position for nailing:Hip AdductedUnobstructed AP &
lateral imagingFracture Reduced(?)
Position for nailing:Hip AdductedUnobstructed AP &
lateral imagingFracture Reduced(?)
Strong traction (without well leg countertraction) abducts fractured hip and prevents gaining proper entrance site
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Strong traction (without well leg countertraction) abducts fractured hip and prevents gaining proper entrance site
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•Both feet in txnBoth feet in txn
•Fx: flexed & addFx: flexed & add
•Well leg extended & Well leg extended & abductedabducted
• Lateral Xray: a little Lateral Xray: a little different, but adequate different, but adequate
The solution is the “Scissors position” for the extremities
The solution is the “Scissors position” for the extremities
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Guide Pin InsertionGuide Pin Insertion
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(Usually by hand…)Guide Pin InsertionGuide Pin Insertion
Ostrum, JOT 05: The entrance isOstrum, JOT 05: The entrance is at the trochanteric tip or slightly at the trochanteric tip or slightly MEDIALMEDIAL
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Ream a channel for implant!
(don’t just displace the fracture as you pass reamer through it)
Ream a channel for implant!
(don’t just displace the fracture as you pass reamer through it)
Medial directed force prevents fracture Medial directed force prevents fracture gapping during entrance reaminggapping during entrance reaming
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Achieve a Neck-Shaft Axis > 130°Achieve a Neck-Shaft Axis > 130°
Use at least a 130° nail
Varus CorrectionsAdvance nailIncrease tractionABDUCT extremity!! (adduction only necessary
at time of nail insertion)
Use at least a 130° nail
Varus CorrectionsAdvance nailIncrease tractionABDUCT extremity!! (adduction only necessary
at time of nail insertion)
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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 ManagementPostoperative Management
Koval, et. al,JBJS(A)’98Koval, et. al,JBJS(A)’98Koval, et. al,JBJS(A)’98Koval, et. al,JBJS(A)’98
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Epilogue: intertrochsEpilogue: intertrochs
(Questions without good answers)(Questions without good answers)
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Where’s the evidence??Where’s the evidence??
Unanswered questionsUnanswered questions
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Minimally invasive PLATE fixation ??Minimally invasive PLATE fixation ??
2 hole DHSBolhofnerDipaola
PCCPGotfried
2 hole DHSBolhofnerDipaola
PCCPGotfried
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Which nail design is best ??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 ?
Proximal diameter?Nail Length?Distal interlocking?
Proximal screw ?
Sleeve or no sleeve? Loch & Kyle, JBJS(A)‘98
One or two needed ?
Nobody knows!
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Proximal fixation: 1 or 2 screws?
Kubiak, JOT ‘04
Proximal fixation: 1 or 2 screws?
Kubiak, JOT ‘04
IMHS vs Trigen in vitro (cadaveric) testingResults: 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) testingResults: No difference in fx sliding or collapse No difference in rigidity or stability Trigen with higher ultimate strength @ failure
Clinical significance??Nobody knows!
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Small Screws protect lateral wall
Only relevant for plate fixation?
Gotfried, CORR ‘04
Im, JOT ‘05
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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
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Thigh pain from short, locked nails?Periprosthetic fracture: Still an issue?Anterior cortex perforation with long nails?
Cost/ benefit?
-Nobody knows--Nobody knows-
6% impinge/ 2% fx Robinson, JBJS(A) 05
Long vs.short nails?Long vs.short nails?
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Just when you think you know whats best--
Don’t forget Ex-Fix!Just when you think you know whats best--
Don’t forget Ex-Fix!
RCT n=40 Exfix +HA vs DHSFaster ops, fewer txfusions, no comps
Moroni, et al. JBJS(A) 4/05
?
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Ex-fix (HApins) vs DHS Randomized/prospective trial of 40 pts.
Moroni, et al. JBJS(A) 4/05
Ex-fix (HApins) vs DHS Randomized/prospective trial of 40 pts.
Moroni, et al. JBJS(A) 4/05Patients65yo+ walking women with osteoporosis
ResultsFaster operations with Fewer transfusionsLess post op pain, similar final functionNo pin site infxs, no increased post op careIncreased pin torque on removal @ 12 wksOne nonunion
Patients65yo+ walking women with osteoporosis
ResultsFaster operations with Fewer transfusionsLess post op pain, similar final functionNo pin site infxs, no increased post op careIncreased pin torque on removal @ 12 wksOne nonunion
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Conclusions: Remember Kaufer’s Variables
Conclusions: Remember Kaufer’s Variables
Uncontrolled factorsFracture GeometryBone Quality
Surgeon controlled factorsQuality of ReductionImplant PlacementImplant Selection
Uncontrolled factorsFracture GeometryBone Quality
Surgeon controlled factorsQuality of ReductionImplant PlacementImplant Selection
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Position screw centrally and
very deep(TAD≤20mm)
Position screw centrally and
very deep(TAD≤20mm)
Implants have different traits-choose wisely
Implants have different traits-choose wisely
Conclusions: Conclusions:
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Things change Things change
Conclusions: Conclusions:
Healing is no longer “success” Deformity & function matter Perioperative insult counts
Healing is no longer “success” Deformity & function matter Perioperative insult counts
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Audience ResponseQuestions!
(save 5-8 minutes for these)
Audience ResponseQuestions!
(save 5-8 minutes for these)
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81 y.o. female slipped & fell
3 part IT fx
81 y.o. female slipped & fell
3 part IT fx
Post-op X-raysPost-op X-rays
Discuss:Discuss:
Did the surgeon do a good Did the surgeon do a good job?job?
Yes or NoYes or No
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Did the surgeon do a good job?
Did the surgeon do a good job? Yes No
Yes No
Answer before advancing.Answer before advancing.
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A.The reduction is satisfactoryB. The TAD (screw position) is OKC. Both are satisfactoryD. Neither are satisfactory
…Choose Best Answer
A.The reduction is satisfactoryB. The TAD (screw position) is OKC. Both are satisfactoryD. Neither are satisfactory
…Choose Best Answer
Now, consider specifically:Now, consider specifically:
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3months 3months
6 months
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Post op
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The TAD was acceptable but the reduction was grossly short
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Did the surgeon do a good job?
Did the surgeon do a good job?
Yes No
Yes No
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27yo jogger struck by car, closed, isolated injury
27yo jogger struck by car, closed, isolated injury
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27yo jogger struck by car27yo jogger
struck by car I’d reduce & fix with:
A. 95° bladeB. DCS plateC. “Recon” NailD. DHSE. Intramedullary hip screw (PFN, TFN, IMHS, GAMMA)
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A.The reduction is satisfactoryB. The TAD is satisfactoryC. Both are satisfactoryD. Neither are satisfactory
A.The reduction is satisfactoryB. The TAD is satisfactoryC. Both are satisfactoryD. Neither are satisfactory
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*
*
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Progressive pain 11-14 weeks(varus + plate is rarely good)
Progressive pain 11-14 weeks(varus + plate is rarely good)
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I’d Bonegraft & revise with:
A. 95° bladeB. DCS plateC. “Recon” NailD. DHSE. IMHSF Other
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95° DCS + autoBG95° DCS + autoBG
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71 yo renal txplnt pt c CHF71 yo renal txplnt pt c CHF
What to do??What to do??
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If my patient, I would use: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
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percutaneous reduction
percutaneous reduction
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Uneventful Healing, WBATUneventful Healing, WBAT
6wks 12wks6wks 12wks
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