L03 intertrochanteric fx
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Transcript of L03 intertrochanteric fx
Intertrochanteric Hip Fractures
Steven Morgan, MD
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
Intertrochanteric Femur
• Intertrochanteric Femur – Extra-capsular
femoral neck – To inferior border
of the lesser trochanter
Incidence
• 250,000 Hip Fractures a Year
• Double by 2040 to 500,000
• 50% are Intertrochanteric Fractures
Demographics
• 90% >65y/o
• F>M
• Peak @ 80y/o
Etiology
• Osteoperosis
• Low energy fall– Common
• High Energy– Rare
Prevention
• Prevention & Active Treatment of Osteoporosis
• Fall Prevention
• Minimize Fall Impact
Fall Prevention
• Etiology of Falls Multifactorial– Medical Care– Avoid Drug Interactions– Vision Correction
• Glasses, Cataract Surgery– Improve Physical Condition
• Strength, Balance, co-ordination
Decreasing Fall Impact
• Padded Floors
• Hip Pads
– Decrease the impact– Decrease risk of fracture
Physical Presentation
• Involved Extremity
– Short
– External Rotated
Radiographs
• Plain Films– AP Pelvis– Cross
Table Lateral
Radiographs
• Plain Films– AP Pelvis– Cross
Table Lateral
Special Studies• CT Scan Rarely
Indicated• Bone Scan
– Occult Fractures– Sensitivity 100% @ 72hrs
• MRI– Occult Fractures– Sensitive in first 24
hrs
Perioperative Medical Management
• Optimize Medical Problems
• DVT Prevention
• Perioperative Antibiotics
• UTI Treatment
• Nutritional Optimization– Decrease 1yr Mortality
Classification
• Multiple Classifications– Stable vs Unstable
– Evan
– Evans-Jensen
– Muller AO/ASIF
• OTA– Muller AO/ASIF System
Classification
• Stable• Resists Medial &
Compressive Loads• With Anatomic
reduction and fixation
Classification
• Unstable• Collapses in varus
or shaft medializes despite anatomic reduction with fixation
OTA AO/ASIFClassification
• 31-A1– Two Part Fracture
– No Communution
– Fracture does not enter the lateral cortex
– Stable
OTA AO/ASIFClassification
• 31-A2– Two Part Fracture– Communution– Fracture does not
enter the lateral cortex
– Unstable
OTA AO/ASIFClassification
• 31-A3– Two Part Fracture– Communution– Fracture enters the
lateral cortex– Reverse Obliquity
Fracture– Unstable
Goals of Treatment
• Obtain A Stable Reduction
• Internal Fixation– Good Position
– Mechanically Adequate
• Permit Immediate Transfers & Early Ambulation
Intra-Operative Positioning
• Hemilithotomy Position– un-injured limb
• Hip Flexed Abducted• Knee Flexed
• Scissors Position– un-injured limb
• Extended Hip
Intra-Operative Flouroscopy
Fracture Reduction
• Neck / Shaft Axial Alignment
• Translational Displacement
• Anatomic Reduction of Individual Fragments Not Necessary
• Reduction Maneuver– Traction
– Internal Rotation
Implant Options
• Compression Hip Screw & Side Plate
• Intramedullary Sliding Hip Screw
• Calcar Replacing Prosthesis
Implant Positioning
• Centered In The Femoral Head– AP View & Lat View– Not Center in the Neck
• High Angle Implant– Center Center-Head
• Important Variable in Bone-Implant Construct
x
Tip-Apex Distance (TAD)
• TAD – Strong Predictor of Cut
Out
• TAD <25mm– Failure Approaches Zero
• TAD >25mm– Chance of failure
increases rapidly
Implant Options
• Compression Hip
Screw & Side Plate
– Controlled Impaction
of Fracture
– Higher Angles Greater
Tendency for
Impaction
Implant Options
• Intramedullary Sliding Hip Screw– Decreased Implant
Bending Strain– Potential Percutaneus
Technique– Inter Troch Shaft– Reverse Obliquity– Pathologic Shaft
Fracture
Implant Options• Calcar Replacing
Prosthesis– Indications
• Pathologic Fracture• Sever Osteopenia• Severe Communution• Rheumatoid Arthritis
– Benefits• Early Weight Bearing
– Problems• Greater Trochanter
Special Fractures
• Reverse Obliquity
– Fracture in Lateral
Cortex
– Untable With Sliding
Hip Screw
– Im Nail or Fixed Angle
Device
Reverse Obliquity Fracture
• DCS
• Blade Plate
• IM Nail
• Resist Medial Shaft
Displacement
Cement Augmentation
• Severe Osteopenia
• Poymethyl Methacrylate (PMMA)
• Improves Screw Purchase
• Augment Deficient Medial Cortex
• Prevent Screw Cut Out
Rehabilitation• Mobilize
– Weight Bearing As Tolerated– Cognitive Intact Patients Auto Protect– Unstable Fractures = Less WB– Stable Fractures = More WB
• No Difference @ 6 weeks Post op
• Follow Up @ 1 Yr 3% Revision Rate– Not Different from historical Controls
Failed Fixation
• Screw Cut Out
• Screw Barrel
Disengagement
Salvage of Failed Fixation
• Angled Blade Plate
or Hip Screw
• Arthroplasty
– Calcar Replacement
Outcome• Mortality
– 7-27% 3 months post-op
– # of Medical Problems
– # Post-OP Complications
• Function– 40% Pre-Injury
Ambulatory Status
– 40% Ambulatory Increased Dependence
– 12% Household Ambulators
– 8% Non AmbulatorsKoval et al
Questions
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