Pearls & Pitfalls of Managing Intertrochanteric Fractures with SHS

5/27/2018 Pearls & Pitfalls of Managing Intertrochanteric Fractures with SHS

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PEARLS & PITFALLS OF MANAGINGINTERTROCHANTERIC FRACTURES

WITH D.H.S

DR. ZAKRIA TARIQPGR, ORTHOPEDICS


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INTERTROCHANTERIC FRACTURES

Intertrochanteric or Pertrochanteric orPeritrochanteric

Accounts for nearly 50% of all proximal femurfractures

Average patient age of incidence is 66-76yrs

In females, annual incidence is 63/100,000population per year while it is 34/100,000 in

males (USA) Female to male ratio 2:1 to 8:1, likely because of

postmenopausal metabolic changes in bone


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Some factors found to be associated with

intertrochanteric rather than femoral neckfractures

Advancing age

Increased number of comorbidities

Increased dependency in activities of daily living

A history of other osteoporosis related (fragility)

fractures


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ANATOMY Intertrochanteric fracture occurs in the region between G.T

and L.T of proximal femur Occasionally extend into subtrochanteric area

Extracapsular fractures

Occur in cancellous bone with an abundant blood supply

Nonunion and osteonecrosis are not major problems Deforming forces produce shortening, ER and varus

position at the fracture. Abductorsdisplace GT laterally & proximally

Iliopsoasdisplace LT medially & proximally

Hip Flexors, Extensors & Adductors- pull distal fragment proximally

Fracture stability determined by presence of posteromedialbony contact, which acts as a buttress against fracturecollapse


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MECHNISM OF INJURY

IN YOUNGER INDIVIDUALS

Usually high energy trauma such as RTA or fall

from height

IN ELDERLY

90%result from a simple fall

Most fractures from a direct impact to GT area


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MECHNISM OF INJURY

The tendency to fall increases with patient age and is

exacerbated by several factors including

poor vision,

decreased muscle power, labile blood pressure,

decreased reflexes,

vascular disease, and

coexisting musculoskeletal pathology.


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CLINICAL EVALUATION

Patients presentation vary depending upon

displacement

Displaced fractures are non ambulatory on

presentation, with shortening and ER of lower

extremity

Pain is evident on attempted range of hip

motion

Nondisplaced fractures may go unnoticed


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CLINICAL EVALUATION

Patient may experience delay beforepresentation at hospital

Mostly are dehydrated with nutrition

depletion at presentation Potential for VTE, pressure ulceration as well

as hemodynamic instability

Intertrochanteric fractures may be associatedwith as much as a full unit of hemorrhage intothe thigh.


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RADIOGRAPHIC EVALUATION AP view of Pelvis

Allows comparison of involved with contralateral side

Can help to identify nondisplaced fractures

Lateral view

Assess posterior communition of proximal femur AP & Cross Table View of the involved proximal femur

Preferred over frog leg lateral as latter requires FABERof

the affected leg and involves risk of fracture displacement

Physician assisted IR view of injured hip (10-15 degree)

IR offsets the anteversion of femoral neck

Provides true AP view of the Proximal femur


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RADIOGRAPHIC EVALUATION

MRI imaging study of choice

Delineates nondisplaced or occult fractures that are not

apparent on plain radiographs

Reveals fracture within 24 hours of injury

CT Scan & Bone Scan

where MRI contraindicated


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BOYD AND GRIFFIN CLASSIFICATION

Type I:A single fracture along the intertrochanteric line, stable and easily reducible.

Type II:

Major fracture line along the intertrochanteric line with comminution in thecoronal plane.

Type III:Fracture at the level of the lesser trochanter with variable comminution and

extension into the subtrochanteric region (reverse obliquity).

Type IV:Fracture extending into the proximal femoral shaft in at least two planes.


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TYPE I TYPE II

TYPE III TYPE IV


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EVANS CLASSIFICATIONType I:

(A) Stable:

- Undisplaced fractures.

- Displaced but after reduction overlap of the medial cortical

buttress make the fracture stable.

(B) Unstable:

- Displaced and the medial cortical buttress is not restored by

reduction of fracture.

- Displaced and comminuted fractures in which the medial corticalbuttress is not restored by reduction of the fracture.

Type II: Reverse obliquity fractures.


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UNDISPLACED

DISPLACED

but reduced

DISPLACED

not Reduced

REVERSEDOBLIQUITY

COMMUNITED

Trochanteric fractures. (Reproduced with permission and copyright of the British Editorial Society

of Bone and Joint Surgery. Ewans EM. The treatment of trochanteric fractures of the femur.J Bone

Joint Surg 1949;31-B:190

203.)


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OTA CLASSIFICATION31-A Femur, proximal trochanteric

31-A1 Peritrochanteric simple

31-A1.1 Along intertrochanteric line

31-A1.2 Through greater trochanter

31-A1.3 Below lesser trochanter

31-A2 Peritrochanteric multifragmentary

31-A2.1 With one intermediate fragment

31-A2.2 With several intermediate fragments

31-A2.3 Extending more than 1 cm below lesser trochanter

31-A3 Intertrochanteric

31-A3.1 Simple oblique

31-A3.2 Simple transverse

31-A3.3 Multifragmentary


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Otota CLASSIFICATION


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UNUSUAL FRACTURE PATTERNS

BASICERVICAL FRACTURES located just proximal to or along the intertrochanteric

line

Anatomically included in femoral neck fractures

Usually extracapsular Behave and treated as intertrochanteric fractures

At greater risk for AVN than the more distalintertrochanteric fractures

Lack the cancellous interdigitation seen with fracturesthrough intertrochanteric region

More likely to sustain rotation of femoral head duringimplant


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UNUSUAL FRACTURE PATTERNS

REVERSE OBLIQUITY FRACTURES

Unstable fractures.

An oblique fracture line extending from medial

cortex proximally to lateral cortex distally.

Location and direction of fracture line results in a

tendency to medial displacement from the pull of

adductors. Treated as subtrochanteric fractures.


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TREATMENT

NONOPERATIVE INDICATIONS

Patients who are at extreme medical risk for surgery

Demented nonambulatory patients with mild hip pain

Nondisplaced fractures can be considered for nonoperative

because displacement changes neither operation type nor

outcome

Early bed to chair mobilization

Avoid complications like poor pulmonary toilet,

atelectasis, venous stasis, pressure sores.

Resultant hip deformity is both expected and accepted in

cases of displacement


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TREATMENT

OPERATIVE GOAL

Stable internal fixation to allow early mobilization and fullweight bearing ambulation.

STABILITY OF FRACTURE FIXATIONdepends on Bone quality Fracture pattern

Fracture reduction

Implant design

Implant placement

TIMING OF SURGERY Should be performed in timely fashion once the patient is

medically stabilized


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OPTIONS

Available options for treating intertrochanteric

fractures include -

SLIDING HIP SCREW

INTRAMEDULLARY HIP SCREW NAIL

EXTERNAL FIXATION

PROSTHETIC REPLACEMENT


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EVOLUTION OF SLIDING HIP SCREW

Fixed-Angle Nail-Plate Devices First successful implants were fixed-angle nail-plate devices (e.g., Jewett nail, Holt nail)

Consisting of a tri-flanged nail fixed to a plate at an angle of 130 to 150 degrees

While these devices provided stabilization of the femoral head and neck fragment to the

femoral shaft,

They did not allow fracture impaction.

Sliding-nail-plate Devices

Experience with fixed-angle nail-plate devices indicated the need for a device that

would allow controlled fracture impaction.

This gave rise to sliding nail-plate devices (e.g., Massie nail, Ken-Pugh nail),

Massie nail ,Ken-Pugh nail consisting of a nail that provided proximal fragment fixation

and a side plate that allowed the nail to telescopewithin a barrel allowing bone on

bone contact


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The sliding nail-plate devices gave rise to

Sliding Hip Screw Devices

The sliding hip screw is the most widely used implant for

stabilization of both stable and unstable intertrochanteric

fractures.

Sliding hip screwside plate angles are available in 5 degree

increments from 130 to 150 degrees.

The 135 degree plate is most commonly utilized

this angle is easier to insert in the desired central position of thefemoral head and neck than higher angle devices and creates less

of a stress riser in the subtrochanteric region.


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SLIDING HIP SCREW

The most important technical aspect of screw

insertion are

Placement within 1 cm of subchondral bone to

provide secure fixation

Central position in the femoral head (Tip ApexDistance)


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TIP-APEX DISTANCE

This can be used to determine lag screw position

within femoral head.

This measurement, expressed in millimeters, is the

sum of distance from the tip of lag screw to the apexof femoral head on both AP and lateral radiographic

views (after controlling for radiographic

magnification).

The sum should be


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SURGICAL PEARLS FOR INSERTION OF A SLIDING HIP

SCREW

Ascertain that there is no impingement of the labia orscrotum from the fracture table

Assess the fracture reduction before prepping the patient and

ensure that non-obstructive biplanar radiographic

visualization of the entire proximal femur, including the hipjoint, is obtainable

Check for residual varus angulation, posterior sag, or

malrotation prior to starting the procedure

Use a 135 degree angle guide to insert the guide pin Position the guide pin in the center of the femoral head and

neck on both the AP and lateral planes within 1 cm of the

subchondral bone


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SURGICAL PEARLS FOR INSERTION OF A SLIDING HIP

SCREW

Ream the femoral neck and head under image

intensification to detect guide pin advancement

Tap the entire screw path to prevent femoral head

rotation during lag screw insertion Confirm a minimum of 20 mm available for lag

screw/barrel slide

Impact the fracture before insertion of the plate holding

screws Use a compression screw if the lag screw cannot be

visualized within the plate barrel


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PITFALLS WITH USE OF A SLIDING HIP SCREW

Misinterpretation of the fracture pattern. This pitfall can be avoided by obtaining both AP and cross-

table lateral x-rays when evaluating proximal femurfractures. If these x-rays do not clarify the nature of thefracture pattern, an x-ray taken with the extremity internally

rotated should be taken. Use a sliding screw for the reverse obliquity type pattern.

Place the lag screw away from the center-center positionand farther than 1 cm from the subchondral bone.

Bending the guide pin during reaming. Bending the guide pin within the reamer resulting in intra-

articular or intra-pelvic penetration.


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PITFALLS WITH USE OF A SLIDING HIP SCREW

Loss of reduction during lag screw insertion. During reaming or lag screw insertion, rotation of the proximal

fragment with loss of fracture reduction can occur. To preventrotation of the proximal fragment, the authors routinely tap thefemoral head and neck prior to lag screw insertion.

Improper lag screw-plate barrel relationship. When a sliding hip screw loses its capacity to slide, it behaves as

a fixed-angle device and is at risk for multiple complications.

Disengagement of the lag screw from the barrel. This uncommon complication results from inadequate lag

screw-plate barrel engagement secondary to use of either ashort lag screw or short barrel side plate.


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VARIATIONS ON THE SLIDING HIP SCREW DESIGNNAME CHARACTERISTICS ADVANTAGES DISADVANTAGES

Conventional Sliding

Hip screw

(SHS)

Lag screw and side

plate

1. Controlled

fracture collapse

2. Well established

device

3. Cost effective

1. Limb shortening

2. Fracture deformity

Variable Angle SlidingHip Screw (VHS)

Angular adjustment ofside plate barrel

1. Reduced inventory2. Allows free hand

guide pin insertion

3. Allow fracture

adjustment one

implant inserted

Beefed up proximalwidth of plate

Talon compression Hip

screw

Prongs protrude from

lag screw

Increased purchase in

femoral head

Difficulty with

hardware removal

NAME CHARACTERISTICS ADVANTAGES DISADVANTAGES


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C C S CS G S S G S

Trochanteric stabilizing

plates

Plate attaches to

conventional 4-hole side

plate to buttress the GT

1. Limits the amount of

fracture collapse

2. Allows screw fixation

of GT

1. Compromise fracture

union

2. Trochanteric bursitis

3. Requires additional

exposure

4. expensive

Medoff plate Biaxial loading plate 1. Limits the amount of

facture collapse

2. Expands use of SHSto S/T and Reverse

obliquity fractures

1. Expensive

2. Learning curve

3. Only available in 135degree angle

Percutaneous

compression plate

(PCCP)

1. Two smaller

diameter lag screw

2. Designed for

percutaneous

insertion

1. Less exposure

2. Less blood loss

3. Limited fracture

collapse

4. Better rotational

control of femoral

head

1. Expensive

2. Learning curve

3. Only available in 135

degree angle


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Talon compression hip screw Trochanteric Stabilizing Plates


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Percutaneous Compression Plate Medoff plate Biaxial Sliding Hip Screw


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INTRAMEDULLARY HIP SCREW NAIL

Combines features of sliding hip screw and intramedullary nail Indicated in unstable fractures

intertrochanteric fracture with subtrochanteric extension

reverse obliquity fractures

Advantages Theoretically, these implants can be inserted in a closed

manner with limited fracture exposure, decreased bloodloss, less tissue damage than sliding hip screw.

Subjected to a lower bending movements than sliding hipscrew owing to their intramedullary location.

Limits the amount of fracture collapse, compared withsliding hip screw.

No clinical advantage of intramedullary hip screwcompared with sliding hip screw in stable fracture pattern.


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EXTERNAL FIXATION Not commonly considered for treatment of intertrochanteric fractures

Early experiences with external fixator for intertrochanteric fracturesassociated withpin loosening, infection and varus collapse.

Indicated in patients at unacceptably high risk for complication related togeneral or regional anesthesia

One or two half pins placed into femoral neck within 10 mm of subchondralbone.

Two or three half pins placed in proximal femur. Satisfactory healing rates 95-100%

Advantages Shorter operative time,

minimal blood loss and

application with local anesthetic with adjuvant analgesia

Duration of external fixation averages 90 days

Complications Malalignment in varus - 12%

Pin tract complication 7% to 44 %

Progression to osteomyelitis - rare


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PROSTHETIC REPLACEMENT INDICATIONS

Elderly, debilitated patient with a communited, unstableintertrochanteric fracture in severely osteoporotic bone

Unsuitable candidates for repeated Internal Fixation

Disadvantages Greater implant cost

More extensive procedure than ORIF Greater blood loss

Longer surgical and anesthetic time

Potential for more frequent complications

Complications

Hip dislocation (3% Hemiarthoplasty; 45% THR) Pressure sores

Pulmonary infections, atelectasis

Periprosthetic fracture

Femoral nonunion


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IMPLANT CHOICE FOR INTERTROCHANTERIC

FRACTURE STABILIZATION (ROCKWOOD)

STABLE FRACTURE PATTERN Sliding hip screw with a two hole side plate

UNSTABLE FRACTURE PATTERN

Intramedullary-type hip screw

BASICERVICAL FRACTURE Sliding hip screw with two hole side plate and anti-rotation

screw

REVERSE OBLIQUITY AND INTERTROCHANTERICFRACTURE WITH SUBTROCHNATERIC EXTENSION Intramedullary-type hip screw


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POSTOPERATIVE CARE Mobilization of hip fracture patients out of bed and ambulation training

should be initiated on post-op day 1 Allow weight bearing as tolerated

Often difficult for elderly patients with decreased upper extremity

strength to comply with partial weight bearing protocol

Restricted WB after hip fracture has little biomechanical justification

Moving around in bed and use of bedpan generates force across the hip

Foot and ankle ROM exercises produce substantial load on femoral head

secondary to muscle contraction

Ecker et al., Unrestricted WB does not increase complication rates

following fixation of intertrochanteric fractures

62 cases with #P/T treated with DHS

early WB-22, non WB for 6 weeks-33, no ambulation-7. Follow up 15 months

3 required revision surgery secondary to nonunion, all three occurred in

unstable fractures

No effect of WBon need for revision surgery.


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COMPLICATIONS

LOSS OF FIXATION

NONUNION

MALROTATION DEFORMITY

OTHER Complications


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LOSS OF FIXATION Commonly result from varus collapse of proximal fragment with

cutout of lag screw from the femoral head Incidence - 20%in unstable fractures

Lag screw cutout from femoral head occurs within 3 months ofsurgery

Causes of lag screw cutout

Eccentric placement of lag screw within femoral head - most common

Improper reamingsecond channel created

Inability to attain a stable reduction

Excessive fracture collapse such that sliding capacity of device isexceeded.

Inadequate screw-barrel engagement, which prevents sliding Severe osteopenia, which precludes secure fixation.

Management

Acceptance of deformity

Revision ORIF with bone cement

Conversion to prosthetic replacement


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NONUNION

Rare as fracture occurs through well vascularized bone


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MALROTATION DEFORMITY

Results from Internal Rotation of distal fragment at thetime of internal fixation.

In unstable fractures, distal and proximal fragments

may move independently

Place distal fragment in neutral to slight external rotation

during fixation of plate to the shaft

When severe and interferes with ambulation, revision

surgery with plate removal and rotational osteotomy offemoral shaft is done.


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OTHER COMPLICATIONS With full length IMnails, impingement or perforation of

distal aspect of nail on the anterior femoral cortex canoccur, secondary to a mismatch of nail curvature andfemoral bow.

Z-effect- most common with dual screw CMTN proximal screw penetrating hip joint

distal screw backing out of femoral head

Osteonecrosis

Rare No association between location of implant within femoral head

and development of ON

Side plate separation and lag screw migration into pelvis

Use compression screw if inadequate screw-barrel engagement


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OTHER COMPLICATIONS

Traumatic laceration of superficial femoral artery by adisplaced LT fragment

Binding of guide pin within reamer intra-articular or intrapelvic penetration

Periprosthetic fractures first generation short trochanteric gamma nails

Due to large distal diameter , large proximal bend and largedistal screws

Nail breakage either short or long trochanteric nails

Typically occur at lag screw site area of maximal stress andthinnest metal


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Pearls & Pitfalls of Managing Intertrochanteric Fractures with SHS

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