Lecture Objectives
Review:
Principles of treatment
Introduce:
Recent Evidenced
based med
Suggest:
Su
Co rge
ntr on
oll
ed
!
Postoperative ambulation
Postoperative complications
Parker, others)
(Cedar, Thorngr
IT Fx / year in U.S.
130,000
better!!
We must do
Preoperative Management
the evidence suggests:
Anderson, JBJS(B) 93
Intertrochanteric Femur
Anatomic considerations
Capsule inserts on IT line
anteriorly, but at
midcervical level
posteriorly
Muscle attachments
determine deformity
Radiographs
Plain Films
AP pelvis
Cross-table lateral
ER Traction view
ncontrolled factors
Bone Quality
Fracture Geometry
ontrolled factors
Quality of Reduction
Implant Placement
Implant Selection
Kaufer, CORR 1980
This lecture will examine
each factor
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
Fracture
Classification in
2006
31
AO / OTA
Stable
Unstable
AO/OTA31A3:
A 33 year old pt with intertrochanteric fracture following a fall from heightNote the dense, cancellous bone throughout the proximal femur;
CPPC
15% increased yield strength, stiffer
Uncontrolled factors
Fracture Geometry
Bone Quality
t
e
g !!
to ght
d ri
e
e
Kaufer,
CORR
N eKauffer,
s80e CORR 1980
th
Quality of Reduction
Implant Placement
Implant Selection
Fracture Reduction
Fracture Reduction
Joystick
etc.
Tip-Apex Distance =
Xlat
Xap
Xlat
JBJS (A) 95
Baumgaertner, Curtin,
Lindskog, Keggi
Reduction Quality
p = 0.6
Screw Zone
Increasing Age
p = 0.002
Increasing TAD
p = 0.0002
p = 0.6
JBJS (A) 95
Baumgaertner, Curtin,
Lindskog, Keggi
Very Deep
(TAD<25mm)
Best bone
No moment arm for
rotational instability
Maximum slide
Validates reduction
IM Fixation:
Theoretical Biologic Advantages
Percutaneous Procedure
GAMMA
The First to Reach
the Market
MJParker,
Parker, International
Orthopaedics '96
CORR 98
Baumgaertner, Curtin, Lindskog,
(* p < 0.05)
Hardy, et.
al JBJS(A) 98
IM
IMFixation:
Fixation:Mechanical
MechanicalAdvantages
Advantages
Key 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
31.A33
2 weeks
7 months
(* p < 0.05)
JBJS(B) 05
Pajarinen,
Clinical
mechanical failure
op-time & blood loss
complications
Medoff, JBJS(A) 91
Lunsj, JBJS(B) 96
Watson, CORR 98
Haidukewych, JBJS(A)
2001
All Significantly
reduced!
JBJS(A) 2002
Sadowski,Hoffmeyer
Intertroch/
subtrochanteric
fxs
Greater mechanical demands,
poorer fracture healing
100% union
81 minutes, 370cc EBL
Reduction Aids
CHS
31
AO / OTA
CHS
????
31
AO / OTA
NAIL
Fractures
Excluded inter/subtrochs fractures (31A.3)
Surgeons
Only 4, all experienced (excluded first 3 TGNs)
Technique
All got spinals, Closed reduction, percutaneous fixation
All overreamed 2mm, all got 130 x 11mm nail, one distal interlock
prn rotational instability (rarely used)
Conclusion
IM Hip Screws
Authors Take
Increasing data to support use for unstable
fracture patterns
Improved anatomy and early function
Iatrogenic problems decreasing with current
designs and technique
Indicated only for the geriatric fracture
Technical
Tips
Patient Set-up
Position for nailing:
Hip Adducted
Unobstructed AP &
lateral imaging
Fracture Reduced(?)
(Usually by hand)
Advance nail
Increase traction
only necessary
at time
of nail insertion)
Postoperative Management
Allow all patients to WBAT
Patients self regulate force on hip
No increased rate of failure
Koval, et. al,JBJS(A)98
Unanswered questions
PCCP
Gotfried
Proximal diameter?
Nail Length?
Distal interlocking?
Proximal screw ?
Sleeve or no sleeve?
JBJS(A)98
Nobody
knows!
Clinical significance??
Nobody
knows!
6% impinge/ 2% fx
Robinson, JBJS(A) 05
knows-Nobody
?
RCT n=40 Exfix +HA vs DHS
Faster ops, fewer txfusions, no comps
Moroni, et al. JBJS(A) 4/05
Patients
Results
Faster operations with Fewer transfusions
Less post op pain, similar final function
No pin site infxs, no increased post op care
Increased pin torque on removal @ 12 wks
One nonunion
Conclusions:
Remember Kaufers Variables
Uncontrolled factors
Fracture Geometry
Bone Quality
Conclusions:
Implants have different
traits-choose wisely
Position screw
centrally and
very deep
(TAD20mm)
Conclusions:
Things change
Healing is no longer success
Deformity & function matter
Perioperative insult counts
Audience
Response
Questions!
(save 5-8 minutes for
these)
3 part IT fx
Discuss:
Yes or No
Post-op X-rays
6 months
3months
Post op
A. 95 blade
B. DCS plate
C. Recon Nail
D. DHS
E. Intramedullary
hip
*
*
(varus +
A. 95 blade
B. DCS plate
C. Recon Nail
D. DHS
E. IMHS
F Other
95 DCS + autoBG
What to do??
4. Blade Plate
5. Other
percutaneous
reduction
6wks
12wks
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