Intertrochanteric Hip Fractures

1. Intertrochanteric Hip Fractures Re-written by: Daniel Habashi

2. Intertrochanteric Hip Fracture objectives • Incidence • Mechanism of injury • Physical findings • X-ray assessment • Classification scheme • Treatment goals • Treatment options • Treatment techniques • Complications • Outcomes • Failure of treatment • Salvage procedures

3. Intertrochanteric femur • Intertrochanteric femur • From the extra-capsular femoral neck • To inferior border of the lesser trochanter

4. Incidence • 250K hip fractures a year • Demographics • 90% over 65 years of age • F>M • Peak around 80 y.

5. Etiology • Osteoporosis • Low energy fall – common • High energy – rare

6. Prevention • Prevention and active treatment of osteoporosis • Fall prevention • Minimize fall impact

7. Physical presentation • Involved extremity • Short • External rotated

8. Radiographs • Plain films • AP pelvis • Cross table lateral

9. Special studies • CT scan rarely indicated • Bone scan – occult fractures, sensitive at 72 hours • MRI – occult fractures, sensitive in 1st 24 hours

10. Classification • Multiple classifications • Stable vs. unstable • Evans • Evans-Jensen • Muller AO/ASIF • OTA • Muller AO-ASIF system

11. Classification • Stable • Resists medial and compressive loads • With anatomic reduction and fixation • THERE WAS A PICTURE HERE OF A FRACTURE

12. OTA AO/ ASIF Classification • 31-A3 • Two part fracture • Comminuting • Fracture enters the lateral cortex • Reverse obliquity fracture • Unstable

13. OTA AO/ASIF Classification • There was also 31-A2 but he changed the slide in a matter of a second so:/

14. Goals of treatment • Obtain A stable reduction • Internal fixation • Good position • Mechanically adequate • Permit immediate transfers and early ambulation

15. Intra-operative positioning • Hemilithotomy position

16. Intra-operative fluoroscopy • 2 pictures of it. Nothing important

17. Fracture reduction • Neck / shaft axial alignment • Translational displacement • Anatomic reduction of individual fragments is not necessary • Reduction maneuver • Traction • Internal rotation

18. Implant options • Compression hip screw and side plate • Intramedullary sliding hip screw • Calcar replacing prosthesis

19. Implant positioning • Centered in the femoral head ( AP VIEW and LAT VIEW) • Etc etcect

20. Tip-apex distance (TAD) • TAD – strong predictor of cut out • TAD under 25mm • Failure approaches zero • TAD over 25mm • Chance of failure increases rapidly

21. Implant options • Intramedullary Sliding Hip Screw • Decreased implant bending strain • Potential percutaneus technique • Inter-Troch Shaft • Reverse obliquity • Pathologic shaft fracture

22. Implant options • Calcar replacing prosthesis • Indications • Ewtc etc etc

23. Reverse obliquity fracture

24. Cement augmentation • Severe osteopenia • Polymethylmethacrylate (PMMA) • Improves screw purchase • Augment deficient medial cortex • Prevent screw cut out

25. Rehabilitation • Mobilize • Weight bearing as tolerated • Etc. etc.etc.

26. Failed fixation • Screw cut out • Screw barrel disengagement

27. Salvage of failed fixation

28. Outcome • Mortality • 7-27% 3 months post-op • # of medical problems • # of post-op complications • Function • 40% pre-injury ambulatory status • 40% ambulatory increased dependence • 12% household ambulates • 8% non ambulates