Intertrochanteric Fractures Presenter: Please look at notes to facilitate your talk—

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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

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

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!

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

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

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

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

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

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:


This lecture will examine each factorThis lecture will examine each factor

“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

AO / OTA

31

Stable Stable Unstable Unstable


AO/OTA31A3: AO/OTA31A3: The highly unstable “pertrochanteric” fractures!The highly unstable “pertrochanteric” fractures!


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

83 yo white woman with unstable intertrochanteric fracture:

Note the marked loss of trabeculae



Implants must be placed where the remaining trabeculae reside!

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


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



Need to g

et

these

right!!

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

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

of of Fracture Reduction Fracture Reduction Surgeon controlled factor

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

The AP view before and after lever redution: the medial cortex is restored

Fracture Reduction Fracture Reduction Surgeon controlled factor

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

Screw Position: TADScrew Position: TAD

Tip-Apex Distance = Xap + Xlat Tip-Apex Distance = Xap + Xlat

XlatXlat

XapXap



Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95


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




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




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

What’s the big deal?

What’s the big deal?

IM vs Plate Fixation

IM vs Plate Fixation

Surgeon controlled factor: Implant selection

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

GAMMAGAMMAThe First to Reach The First to Reach

the Marketthe Market

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

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


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

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


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


IM Fixation: Mechanical AdvantagesIM Fixation: Mechanical Advantages

?? !!


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

The nail substitutes for the incompetent posteromedial cortex

31.A33 31.A33

2 weeks 2 weeks 7 months7 months

The nail substitutes for the incompetent lateral cortex

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)

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*


Pajarinen, JBJS(B) ‘05Pajarinen, JBJS(B) ‘05


Ahrengart, CORR ‘02Ahrengart, CORR ‘02

less sliding, shaft medialization* less sliding, shaft medialization*


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


Reverse Oblique Fractures

Reverse Oblique Fractures

IM Fixation: Best Indications


Intertroch + subtrochanteric

fractures

Intertroch + subtrochanteric

fractures

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


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


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

Intertroch/ Intertroch/ subtrochanteric subtrochanteric

fxsfxsGreater mechanical demands,

poorer fracture healing


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


Reduction AidsReduction Aids

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*


AO / OTA

31

CHS

Grossly displaced Stable (31A.1) fracture treated with ORIF

Grossly displaced Stable (31A.1) fracture treated with ORIF


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


AO / OTA

31

CHS

NAIL

????

IM Fixation vs. CHSRandomized/prospective trial of 210 pts.

Utrilla, et al. JOT 4/05


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)


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






No difference:No difference: Re-ops Mobility Residence

Re-ops Mobility Residence

• Transfusions

• Hospital stay

• Transfusions

• Hospital stay

JBJS(A) 2010JBJS(A) 2010

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?

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


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)


Technical Tips

Technical Tips

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

Strong traction (without well leg countertraction) abducts fractured hip and prevents gaining proper entrance site

•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

Guide Pin InsertionGuide Pin Insertion

(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

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

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)

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

Epilogue: intertrochsEpilogue: intertrochs

(Questions without good answers)(Questions without good answers)

Where’s the evidence??Where’s the evidence??

Unanswered questionsUnanswered questions

Minimally invasive PLATE fixation ??Minimally invasive PLATE fixation ??

2 hole DHSBolhofnerDipaola

PCCPGotfried

2 hole DHSBolhofnerDipaola

PCCPGotfried

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!

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!

Small Screws protect lateral wall

Only relevant for plate fixation?

Gotfried, CORR ‘04

Im, JOT ‘05

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

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?

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

?

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

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

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:

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

Audience ResponseQuestions!

(save 5-8 minutes for these)

Audience ResponseQuestions!

(save 5-8 minutes for these)

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

Did the surgeon do a good job?

Did the surgeon do a good job? Yes No

Yes No

Answer before advancing.Answer before advancing.

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:

3months 3months

6 months

Post op

The TAD was acceptable but the reduction was grossly short



Yes No

Yes No

27yo jogger struck by car, closed, isolated injury

27yo jogger struck by car, closed, isolated injury

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)

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

*

*

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

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

I’d Bonegraft & revise with:

A. 95° bladeB. DCS plateC. “Recon” NailD. DHSE. IMHSF Other

95° DCS + autoBG95° DCS + autoBG

71 yo renal txplnt pt c CHF71 yo renal txplnt pt c CHF

What to do??What to do??

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

percutaneous reduction

percutaneous reduction

Uneventful Healing, WBATUneventful Healing, WBAT

6wks 12wks6wks 12wks

Return to Lower Extremity

Index

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Questions/Comments

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Documents

fracture outcome

fracture geometryaoota31a3

reduced fracture

fracture plane

welluncontrolled factor

bone qualitykauffer

cancellous bone

bone qualityimplants