service presentation v1 9_14_10

8/7/2019 service presentation v1 9_14_10

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T H E R I S E A N D F A L L O F I N T E R N A L F I X A T I O N

F R E D E R I C A . M O N T A O , M D

Treatment of displaced femoralneck fracture


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Early Years

y Conservative management involves the use ofreducing the fracture in extension, internal rotationand abduction

y Plaster casting was applied for several monthsy Fractures healed but mortality was high


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Nails

y 1931- Smith PetersenNail with 3 flanges

y Open reduction is necessary

y A central canal in the Smith PetersenNail was made

and invented a targeting devicey Guide was introduced from the trochanter and into

the femoral head

y Nail was knocked in after radiographic

confirmationy Finally, the fracture was compressed with a specially

designed hammer


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More Nails

y Common complication was slipping of the nail

y 1964 Rydell invented the spring loaded nail

y It has 4 flanges and hammered in over a guide pin

which was removed and replaced by a spring pin


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More Nails

y 1982- Hannson introduced the hook pin

y A Rydell nail with the flanges removed and with thesame spring pin

y Primarily used for fixation of slipped capital femoralepiphysis

y 2 pins were used for femoral neck fractures toprevent rotation of the head fragment

y Multiple pinning was thought to provide betterstability thus it would facilitate revacularization ofthe femoral head


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Sliding nail/screw plate

y 1960s- Charnley invented the sliding screw plate forfixation of neck fractures

y His invention became the prototype of sliding

fixation used nowadays for trochanteric fractures


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Screws

y Served as alternative to single nail fixation

y Examples were the Uppsala screw and the von Bahrscrew


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Comparisons of outcome

y Was any one method superior?


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Sliding nail/screw vs pins/screws

y Frandsen & Andersen (1981) RCT study comparingSmith Petersen nail with sliding nail plate: 83/131healed in Smith Petersen group and 89/118 healed in

nail plate groupy Madsen et al. (1987) RCT study comparing sliding

screw plate vs 4 ASIF cancellous screws: Rate ofunion (84%) was better in the screw group


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Sliding nail/screw vs pins/screws

y Elmerson et al. (1995) RCT study comparing hookpins and sliding screw plate: Failure rate was 38%after 2 years with hook pins and 46% with screw

plate


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Rydell vs Hannson nail

y Early studies (1984):More complications on Rydellgroup especially on those with displaced fractures(23/32 vs 12/36)

y Holmberg et al. (1990) RCT : early re-displacementor non-union but not statistically significant for bothmethods

y Sambo et al. (1990) RCT involving 400 patients:

Similar rates of early displacement, on-union, latesegmental collapse and salvage arthroplasty in 2groups


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Uppsala screws vs pins/screws

y Rhenberg and Olreud (1989) RCT: Uppsala screwswas better even after 1 month

y Herngren et al. (1992) RCT comparing Uppsala

screws and Hannson pins: In displaced fractures, re-displacement after 4 months was statisticallycommoner with pins, and the over-all result wasslightly better with screws


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Uppsala screws vs pins/screws

y Lagerby et al. (1998) RCT between 2 Uppsala screwsand 3 Richards screws: No difference incomplications and clinical results


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Arthroplasty

y Charnley (1961): It is probable that immediateprosthetic replacement of the femoral head aftersubcapital fractures of the neck of the femur, in

senile patients will be used more commonly in thefuture in preference to internal fixation.


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Arthroplasty

y The philosophy was that since the fracture healed inmost patients with a displaced neck fracture, the hipor the femoral head should only be replaced only in

patients who really needed it, i.e. After failure offixation or because of femoral head necrosis


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Hemiarthroplasty

y Riska (1971) studied 107 patients with Mooreprosthesis: Patients were easier to mobilize and withless pain

y

Holstein (1975): Same results as with Riskay Tillberg (1976):Mortality was 9% within 6 weeks.

Functional result was 95% of surviving patients; 77%were pain-free and 93% manageds ADL

y The usefullness of reposition and nailing of femoralneck fractures in elderly patients is therefore open toquestion, and primary arthroplasty is recommendedinstead.


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Hemiarthroplasty

y Lindholm et al. (1976): Same results

y Overgaard et al. (1991): Treatment with arthroplastywas advantageous because of the low complication

rate


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y Is there any explanation for why internal fixationbecame the only treatment for about 3 decades?

y Was it to save money, since internal fixation was

cheaper?y Was it to reduce the risks of treatment for old and

fragile patients?

y Was it to facilitate rehabilitation after a less invasive

operation?


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y After all efforts to improve internal fixation itbecame evident that the failure rate in displacedfractures was still not acceptable


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Internal fixation vs arthroplasty

y Jonsson et al. (1996) RCT between hook pin andCharnley hip replacement: After 1 and 2 years, fewerpatients in the replacement group used outdoor

walking aids and were more likely to do their ownshopping


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y Johannson et al. (2000) RCT between fixation with 2Olmed screws and THA with Lubinus SP prosthesis:Hip replacement should be considered in mentaly

healthy, elderly patients with high functionaldemands


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y Parker and Pryor (2000) RCT between fixation with3 cannulated screws and AustinMoorehemiarthroplasty:More re-admissions and

reoperations after internal fixation but the finalfunctional outcome in the groups after 2-3 years wassimilar


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y Gjertsen et al. (2007) Norwegian Arthroplastyregister study: Hip replacement is a good treatmentfor acute fractures as well as late complications.

Increased risks were small and would perhaps havebeen impossible to detect with fewer patients


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y Gjertsen et al. (2008) Norwegian Arthoplastyregister study: Patient satisfaction, pain and qualityof life were better in the group treated with

arthroplasty


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Discussion

y All arguments for internal fixation of displacedfemoral neck fractures in elderly patients haveproven to be wrong

y Hip function was better after a primary replacementand the reduction of quality of life was morepronounced during the first year of treatment in thepatients treated with fixation


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y Should patients with cognitive deficiency, withoutany or with severely reduced walking capacity, oreven bedridden patients be operated on with an

arthroplasty, or is it enough with internal fixation?


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y Probably a widepsread opinion is that internalfixation is to be preferred

y This patient category has usually been excluded in

previous studiesy Rogmark et al. (2002) compared hip arthroplasty

and internal fixation with elderly patients includingthose with cognitive deficiency or prolonged

confusion: 7% failure rate was noted during the 1stpost op year in the arthroplasty group and 36% ininternal fixation group


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y Primary arthroplasty coudl also be recommended forpatients with cognitive impairment

y Internal fixation is still the first choice for non-

displaced fracturesy Young patients with displaced fractures should be

given the chance of healing

y No clear upper age limit


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y The elderly should be treated with an arthroplastybut with a hemiarthroplasty or a total hipreplacement?

y The more active the patient is, the more he/she willbenifit from a total hip even in the 70-80 year agegroup

service presentation v1 9_14_10

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