Intertrochanteric Fractures Optimal Treatment in 2007

2. Lecture Objectives Review: Principles of treatment Understand & Optimize Variables influencing patient and fracture outcome Introduce: Recent Evidenced based med Suggest: Technical Tips to avoid common problems

3. Hip Fracture PATIENT Outcome Predictors 

4. A public heath care cri$i$: 130,000 IT Fx / year in U.S.& will double by 2050�

5. Preoperative Managementthe evidence suggests: �Tune up� correctable comorbidities Operate within 48�; avoid night surgery Maintain extremity in position of comfort General versus spinal anaesthesia?

6. Intertrochanteric FemurAnatomic considerations Capsule inserts on IT line anteriorly, but at midcervical level posteriorly Muscle attachments determine deformity

7. Plain Films AP pelvis Cross-table lateral Radiographs

8. Uncontrolled factors Bone Quality Fracture Geometry Controlled factors Quality of Reduction Implant Placement Implant Selection Factors Influencing Construct Strength:

9. �STABILITY� The ability of the reduced fracture to support physiologic loading

16. Can / Should we strengthen the bone-implant interface? PMMA 12 to 37% increase load to failure Choueka, Koval et al., ActaOrthop �96 CPPC 15% increased yield strength, stiffer Moore, Goldstein, et al., JOT �97 Elder, Goulet, et al., JOT �00 Clinical Factors in 2007 influence use delivery, cost, complications must be considered

17. Uncontrolled factors Fracture Geometry Bone Quality Surgeon controlled factors Quality of Reduction Implant Placement Implant Selection Factors Influencing Construct Strength:

18. 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 hinstability to offset shortening

19. Fracture Reduction Discuss sequence of reduction steps Consider adjuncts to fracture reduction Joystick Elevator Crutch etc. PEARL: look for soon to be published article in JOT on the role of exploiting the anteriormedial cortex in stable, bone on bone reduction for fractures with �sag� deformity seen on lateral!

20. Apex of the femoral head

23. Probability of Cut Out Increasing TAD ->

24. Logistic 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

26. What�s the big deal? IM vs Plate Fixation

31. IM Fixation: Clinical Results No difference for stable fxs Faster & less bloody for unstable fxs Fewer IM complications than Gamma Weaknesses: No stratification of unstable fractures Learning curve issues No anatomic outcomes, wide functional outcomes

32. 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*

34. 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

37. IM Fixation: Selected Clinical Results 5� in neck shaft angle @ 6 wks (all) shaft medialization @ 4mo *

38. Trochanteric Stabilizing Plateplate adjunct to limit shaft medialization major (=20mm screw slide) collapse op time, blood loss ? complications, length of rehab

39. Bi-axial Sliding Hip Screw Biomechanical 50% medial cortical load Olsson, ActaOrthop Scan �87 Clinical mechanical failure op-time & blood loss complications Medoff, JBJS(A) �91 Lunsj�, JBJS(B) �96 Watson, CORR �98

40. Reverse Oblique Fractures

41. 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 Fractures

43. PFN vs 95� sliding screw plate(DCS) RCT of 39 cases done by Swiss AO surgeons PFN (IM) vs Plate Open reductions Op-time Blood tx Failure rate Major reoperations Reverse Oblique Fractures

48. 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

49. Reduction Aids

50. 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

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

53. There is no data to support nailing over sideplate fixation for A1 fractures

55. IM Fixation(TGN) vs. CHSRandomized/prospective trial of 210 pts. Utrilla, et al. JOT 4/05 Patients All ambulatory, no ASA Vs 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)

56. Results Skin to skin time unchanged Fewer blood transfusions needed 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 TGN for most Unstable fxs IM Fixation(TGN) vs. CHSRandomized/prospective trial of 210 pts. Utrilla, et al. JOT 4/05

57. IM Hip Screws Author�s 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

58. IM 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)

59. Technical Tips

60. Patient Set-up Position for nailing: Hip Adducted Unobstructed AP & lateral imaging Fracture Reduced(?)

62. The solution is the �Scissors position� for the extremities

63. Guide Pin Insertion

64. Guide Pin Insertion

66. Achieve a Neck-Shaft Axis > 130� Use at least a 130� nail Varus Corrections Advance nail Increase traction ABDUCT extremity!! (adduction only necessary at time of nail insertion)

67. 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 Management

68. Where�s the evidence??

69. Minimally invasive PLATE fixation ?? 2 hole DHS Bolhofner Dipaola PCCP Gotfried

70. Proximal diameter? Nail Length? Distal interlocking? Proximal screw ? Sleeve or no sleeve? Loch & Kyle, JBJS(A)�98 One or two needed ?

71. Proximal fixation: 1 or 2 screws? Kubiak, JOT �04 IMHS vs Trigen in vitro (cadaveric) testing Results: No difference in fx sliding or collapse No difference in rigidity or stability Trigen with higher ultimate strength @ failure Clinical significance??

75. Just when you think you know whats best--Don�t forget Ex-Fix!

76. Ex-fix (HApins) vs DHS Randomized/prospective trial of 40 pts. Moroni, et al. JBJS(A) 4/05 Patients 65yo+ walking women with osteoporosis 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

77. Uncontrolled factors Fracture Geometry Bone Quality Surgeon controlled factors Quality of Reduction Implant Placement Implant Selection

78. Position screw centrally andvery deep(TAD=20mm)

79. Healing is no longer �success� Deformity & function matter Perioperative insult counts

81. Audience ResponseQuestions!(save 5-8 minutes for these)

82. 81 y.o. female slipped & fell 3 part IT fx Post-op X-rays

83. Did the surgeon do a good job? Yes No

84. A.The reduction is satisfactoryB. The TAD (screw position) is OKC. Both are satisfactoryD. Neither are satisfactory�Choose Best Answer

85. 3months

88. Did the surgeon do a good job? Yes No

90. 27yo jogger struck by car, closed, isolated injury

91. 27yo jogger struck by car

93. A.The reduction is satisfactoryB. The TAD is satisfactoryC. Both are satisfactoryD. Neither are satisfactory

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

97. 95� DCS + autoBG

98. 71 yo renal txplnt pt c CHF

99. 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

100. percutaneous reduction

101. Uneventful Healing, WBAT