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Fractures of the femur

Leeds 2005. AO Principles Course. Fractures of the femur. David L Shaw. Module : Principles of operative management of common fractures. Fractures of the Femoral Shaft (AO 3.2). Why should I fix the #? How should I fix it ? What complications can I expect ?. Paediatric fractures.

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Fractures of the femur

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  1. Leeds 2005 AO Principles Course Fractures of the femur David L Shaw Module : Principles of operative management of common fractures

  2. Fractures of the Femoral Shaft (AO 3.2) • Why should I fix the #? • How should I fix it ? • What complications can I expect ?

  3. Paediatric fractures • See article • Gallows • Hip Spica • Traction J Am Acad Orth Surg 1995 no3 J Am Acad Orth Surg 1995 no3

  4. Why fix the # • Save life • Poly trauma • Save limb • Preserve function • Stabilisation with immediate rehabilitation

  5. Plating Rigid fixation Abs stability LISS LCP Ext fixn IM Nail Choose a method ? • Consider absolute vs relative stability • Consider soft tissues and scars • Consider facilities and equipment J Am Acad Orth Surg 1995 no3

  6. Choose a method 2 • Patient factors • Facilities, time and polytrauma • Damage control orthopaedics J Am Acad Orth Surg 1995 no3

  7. “Get me a nail!”

  8. Rods & Nails The truth is out there! • When is a nail not a nail • Hollow – Slotted – Solid • Why nails fail • Effects of Reaming

  9. Bones & NailsHollow structures • Hollow bones for strength • Early nails were hollow & needed 3 point fixation

  10. Kuntcher - Clover leaf nail • 3 point fixation • Inserted open so no guide wire required

  11. GK & AO – Slotted hollow nail • Allowed guide wire insertion • Flat sheet manufacture

  12. Reaming to increase the contact area

  13. Lets talk about stiffness

  14. Bending StiffnessSecond Moment of Inertia (I) • Tube • I=(Ro4 – Ri4) * ¶/4 •  Radius cubed

  15. Hollow structures are relatively strong for the volume of material • For a given increase in radius torsional and bending stiffness go up to the fourth power • Torsional stiffness roughly 2x inc vs bending as radius • At physiological loads torsional deformation more clinically evident

  16. Slotted nails especially are weak in torsion

  17. The advantage of “Unreamed” The advantage of Solid • Solid Ti nails are strong enough at diameters small enough to be inserted without reaming • Not possible with SS nails • Expensive

  18. “You be the Judge”

  19. For unreamed • Healing • 170 # • Equivalent healing time (19/52) • 55mins quicker • = delayed unions • Reynders Injury 2000

  20. For unreamed • General Results • 164# retrospective series • 93% union rate with UFN • AO type C healed at 6.2mo (ave) • UFN “healing rates comparable with historical standards” • Herscovici JOT 2000

  21. For unreamed • Intramedullary pressure • Clinical trial 38 pts • 5x increased pressure in reamed group • Pressure correlated with fat extravasation • Berger JOT 1997

  22. For unreamed • Poly Trauma • Femur # in polytrauma pts managed by; • Early Total Care • Intermediate Stabilisation • “Damage Control Surgery” • “A significant reduction in the incidence of complications was found ..regardless of the type of fixation” • Garapati & Krettek J of T 2002

  23. Against unreamed method • Healing • 147# • 6 weeks longer to heal • Giannoudis Injury 1997 • 172# • 4 weeks longer to heal • More “technical complications” • Tornetta JOT 2000

  24. Against unreamed method • Stimulation of the inflammatory system • IL6, CD11b, s-ICAM-1, E-selectin & elastase • Reamed vs Unreamed • Evidence of a “second hit” to the immune system • No difference reamed vs unreamed • Giannoudis JBJS(B) 1999 • If you don’t ream you still get a second hit to the immune system

  25. Against unreamed method • Complications • 100 randomised pts • 2x iatrogenic comminution in unreamed • Reaming was “required” in the unreamed group in 3 • Shepherd J Orthop Trauma 2001

  26. For unreamed • Quicker • Simpler • Less equipment • Equivalent healing rate • Less fat embolus • Less H-O • Lower immune “hit”

  27. For reamed • Faster union • Fewer implant related complications • Lung injury not directly & only caused by reaming • “Second hit” not specifically caused by reaming

  28. It’s all about technique

  29. Reaming is a technique Solid nails are implants

  30. Solid nail ? • Who would put a 9mm nail in this pt!

  31. Summary & “Verdict” • Reaming is a technique • Solid vs Slotted vs Cannulated • is a design / manufacturing process

  32. “I always do reamed nails”

  33. Solid Reamed Hollow Unreamed

  34. Solid Reamed Hollow Unreamed

  35. Solid Reamed Hollow Unreamed

  36. Solid Reamed Hollow Unreamed

  37. Solid Reamed Hollow Unreamed

  38. Summary • Chose the smallest nail which is strong enough for the patient and his/her injury • Ream if necessary to put the appropriate size of nail in for the patient & injury • Don’t confuse implants with technique

  39. Other peoples’ complications • General complications • Specific # related comlpications • Malunion

  40. Cambell’s Operative Orthopaedics • “Malunions after closed treatment are the rule”

  41. Malrotation • > 10 degrees in 8-19% of fractures • JBJS 75 (B) 799-803 • JBJS 66 (A) 529-39

  42. Cambell’s Operative Orthopaedics • “..become significant only if they result in • shortening of more than 2.5 cm • angulated more than 10 degrees • internally or externally rotated to the point that the knee cannot be aligned with forward motion during gait.”

  43. ? How much rotation ? • External rotation less well compensated than internal • 15 degree limit • Based on functional assessments and FPA • Nijmegen group: Injury 35 1270-1278 2004

  44. Malunion • > 2.5 cm shortening • > 10° angular deformity • >15° rotation deformity

  45. Malunion • > 2.5 cm shortening • > 10° angular deformity • Rotation that the pt can see !

  46. Fractures of the Femoral Shaft (AO 3.2) • Why should I fix the #? • Damage control • Restore function • How should I fix it ? • For the fracture / for the patient • What complications can I expect • Length , Rotation the pt can see

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