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

Intertrochanteric Fractures Presenter: Please look at notes to facilitate your talk— There is too much content for one sitting -edit to your needs— Unanswered clinical issues and audience questions at end of lecture. Michael R. Baumgaertner, MD

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

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  1. Intertrochanteric Fractures Presenter: Please look at notes to facilitate your talk— There is too much content for one sitting -edit to your needs— 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

  2. Lecture 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

  3. Uncontrolled Surgeon Controlled! 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)

  4. Even when surgery is “successful”: • 1-2 units PRBC transfused • 3-5+ days length of stay • 4-12% fixation failure A public heath care cri$i$: 130,000 IT Fx / year in U.S.& will double by 2050… We must do better!!

  5. “Tune up” correctable comorbidities Operate within 48°; avoid night surgery Maintain extremity in position of comfort General versus spinal anaesthesia? Preoperative Managementthe evidence suggests: Zuckerman, JBJS(A) ‘95 Buck’s traction of no value (RCT) Anderson, JBJS(B) ‘93 Randomized, prospective trials (RCTs): no difference Davis, Anaesth & IntCare ‘81; Valentin, Br J Anaesth ‘86

  6. Osteoporosis International “Preoperative Guidelines and Care Models for Hip Fractures” Volume 21, Supplement 4 December 2010 Comprehensive Managementexcellent evidence based single source:

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

  8. ER Traction view when in any doubt!! Radiographs Plain Films • AP pelvis • Cross-table lateral

  9. Factors Influencing Construct Strength: Uncontrolled factors Bone Quality Fracture Geometry Controlled factors Quality of Reduction Implant Placement Implant Selection Kaufer, CORR 1980 This lecture will examine each factor

  10. Uncontrolled factor: Fracture geometry “STABILITY” 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

  11. Stable Unstable AO / OTA 31

  12. Uncontrolled factor: Fracture geometry Stable Unstable

  13. Uncontrolled factor: Fracture geometry AO/OTA31A3: The highly unstable “pertrochanteric” fractures!

  14. Uncontrolled factor: Bone quality 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

  15. Uncontrolled factor: Bone quality 83 yo white woman with unstable intertrochanteric fracture: Note the marked loss of trabeculae

  16. Uncontrolled factor: Bone quality Implants must be placed where the remaining trabeculae reside!

  17. Uncontrolled factor: Bone quality 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 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

  18. Need to get these right!! Factors Influencing Construct Strength: Uncontrolled factors • Fracture Geometry • Bone Quality Surgeon controlled factors • Quality of Reduction • Implant Placement • Implant Selection Kaufer, CORR ‘80 Kauffer, CORR 1980

  19. RCT Desjardins, et al. JBJS (B) ‘93 RCT Gargan, et al. JBJS (B) ‘94 Surgeon controlled factor Fracture Reduction When employing sliding hip screws… • 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

  20. Surgeon controlled factor Fracture Reduction • Discuss sequence of closed reduction steps • Consider adjuncts to fracture reduction Crutch… elevator… joystick…. etc. Lever technique– read this article:

  21. Surgeon controlled factor Fracture Reduction of Double density of medial cortex is evidence of intussuscepted neck into shaft seen on lateral

  22. Traction will not reduce this “sag” but a lever into the fracture will

  23. Traction will not reduce this “sag” but a lever into the fracture will reduce it

  24. Surgeon controlled factor Fracture Reduction The AP view before and after lever redution: the medial cortex is restored

  25. Surgeon controlled factor: Implant position Apex of the femoral head Defined as the point where a line parallel to, and in the middle of the femoral neck intersects the joint

  26. Screw Position: TAD Screw Position: TAD X X ap ap X X lat lat X X X X Tip-Apex Distance = + Tip-Apex Distance = + ap lat ap lat Surgeon controlled factor: Implant position

  27. Surgeon controlled factor: Implant position Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95

  28. Surgeon controlled factor: Implant position Probability of Cut Out Increasing TAD -> Risk of Cut Out Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95

  29. Surgeon controlled factor: Implant position 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 Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95

  30. Dead Center and Very Deep (TAD<25mm) Surgeon controlled factor: Implant position Optimal Screw Placement • Best bone • No moment arm for rotational instability • Maximum slide • Validates reduction

  31. Surgeon controlled factor: Implant selection What’s the big deal? IM vs Plate Fixation

  32. IM Fixation Recent History: Theoretical Biologic Advantages Percutaneous Procedure EBL, Muscle stripping, Complications, Rehab time? Surgical wounds s/p ORIF with IM device

  33. GAMMA The First to Reach the Market

  34. Gamma Clinical Results ± Advantages : +++ +++ Complications : Complications : Bridle Bridle Williams Williams JBJS(B) '91 JBJS(B) '91 Injury '92 Injury '92 Boriani Boriani Leung Leung Orthopaedics '91 Orthopaedics '91 JBJS(B) '92 JBJS(B) '92 Lindsey Lindsey Aune Aune Trauma '91 Trauma '91 ActOrthopScan '94 ActOrthopScan '94 Halder Halder JBJS(B) '92 JBJS(B) '92

  35. Surgeon controlled factor: Implant selection Gamma Nail vs. CHS Gamma Nail vs. CHS 1996 Meta-analysis of ten randomized trials ­ x CHS (p < 0.001) ­ • Shaft fractures: Gamma 3 x CHS (p < 0.001) • Required Re-ops: Gamma 2 ­ ­ x CHS (p < 0.01) • Required Re-ops: Gamma 2 x CHS (p < 0.01) • • IM fixation may be superior for inter/subtroch • IM fixation may be superior for inter/subtroch extension & reverse obliquity fractures extension & reverse obliquity fractures • “ “ • CHS is a forgiving implant when used by CHS is a forgiving implant when used by inexperienced surgeons, the Gamma nail is not” inexperienced surgeons, the Gamma nail is not” MJParker, International Orthopaedics '96 Parker, International Orthopaedics '96

  36. Gamma nails revisited(risk of shaft fracture….)Bhandari, Schemitsch et al. JOT 2009 No more increased risk with nails

  37. Surgeon controlled factor: Implant selection IM Fixation: Clinical Results RCT, IMHS vs CHS, N = 135 • 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 Baumgaertner, Curtin, Lindskog, CORR ‘98

  38. Surgeon controlled factor: Implant selection IM Fixation: Clinical Results Well analyzed RCT, IMHS vs CHS, N = 100 • Longer surgery, less blood loss • Improved post-op mobility @ 1 & 3 months * • Improved community ambulation @ 6 & 12 months * • 45% less sliding, LLD* (* p < 0.05) Hardy, et. al JBJS(A) ‘98

  39. Surgeon controlled factor: Implant selection IM Fixation: Mechanical Advantages IM Fixation: Mechanical Advantages ? ? ! !

  40. 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* * Reduced collapse has been demonstrated in most every randomized study that has looked at the variable

  41. The nail substitutes for the incompetent posteromedial cortex

  42. 31.A33 31.A33 2 weeks 7 months 2 weeks 7 months The nail substitutes for the incompetent lateral cortex

  43. Iatrogenic, intraoperative lateral wall fracture A2 to A3 fx! CHS: Unique risk of failure Palm, et al JBJS(A) ‘07 31% risk in A2.2&3 fxs 22% failure rate (vs. 3% overall)

  44. Surgeon controlled factor: Implant selection IM Fixation: Selected Clinical Results RCT, IMscrew vs CHS, N = 436 • less sliding, shaft medialization* 5° in neck shaft angle @ 6 wks (all) shaft medialization @ 4mo * Ahrengart, CORR ‘02 RCT, IMscrew vs CHS, N = 46 Pajarinen, Int Orth ‘04 • Improved post-op mobility (4 months)* • less sliding, shaft medialization* RCT, IMscrew vs CHS, N = 108 (* p < 0.05) Pajarinen, JBJS(B) ‘05

  45. Surgeon controlled factor: Implant selection Trochanteric Stabilizing Plate (TSP)plate adjunct to limit shaft medialization CHS Improvements: 1975-2010 major (≥20mm screw slide) collapse op time, blood loss ? complications, length of rehab Madsen, JOT '98 Su, Trauma ‘03 Bong, Trauma ‘04

  46. Surgeon controlled factor: Implant selection Reverse Oblique Fractures IM Fixation: Best Indications Intertroch + subtrochanteric fractures

  47. Surgeon controlled factor: Implant selection Reverse Oblique Fractures 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) Haidukewych, JBJS(A) 2001

  48. Surgeon controlled factor: Implant selection Reverse Oblique Fractures 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 • All Significantly reduced! Sadowski,Hoffmeyer JBJS(A) 2002

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

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