L03 intertrochanteric fx

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Intertrochanteric Hip Fractures Steven Morgan, MD

Transcript of L03 intertrochanteric fx

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Intertrochanteric Hip Fractures

Steven Morgan, MD

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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

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Intertrochanteric Femur

• Intertrochanteric Femur – Extra-capsular

femoral neck – To inferior border

of the lesser trochanter

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Incidence

• 250,000 Hip Fractures a Year

• Double by 2040 to 500,000

• 50% are Intertrochanteric Fractures

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Demographics

• 90% >65y/o

• F>M

• Peak @ 80y/o

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Etiology

• Osteoperosis

• Low energy fall– Common

• High Energy– Rare

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Prevention

• Prevention & Active Treatment of Osteoporosis

• Fall Prevention

• Minimize Fall Impact

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Fall Prevention

• Etiology of Falls Multifactorial– Medical Care– Avoid Drug Interactions– Vision Correction

• Glasses, Cataract Surgery– Improve Physical Condition

• Strength, Balance, co-ordination

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Decreasing Fall Impact

• Padded Floors

• Hip Pads

– Decrease the impact– Decrease risk of fracture

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Physical Presentation

• Involved Extremity

– Short

– External Rotated

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Radiographs

• Plain Films– AP Pelvis– Cross

Table Lateral

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Radiographs

• Plain Films– AP Pelvis– Cross

Table Lateral

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Special Studies• CT Scan Rarely

Indicated• Bone Scan

– Occult Fractures– Sensitivity 100% @ 72hrs

• MRI– Occult Fractures– Sensitive in first 24

hrs

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Perioperative Medical Management

• Optimize Medical Problems

• DVT Prevention

• Perioperative Antibiotics

• UTI Treatment

• Nutritional Optimization– Decrease 1yr Mortality

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Classification

• Multiple Classifications– Stable vs Unstable

– Evan

– Evans-Jensen

– Muller AO/ASIF

• OTA– Muller AO/ASIF System

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Classification

• Stable• Resists Medial &

Compressive Loads• With Anatomic

reduction and fixation

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Classification

• Unstable• Collapses in varus

or shaft medializes despite anatomic reduction with fixation

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OTA AO/ASIFClassification

• 31-A1– Two Part Fracture

– No Communution

– Fracture does not enter the lateral cortex

– Stable

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OTA AO/ASIFClassification

• 31-A2– Two Part Fracture– Communution– Fracture does not

enter the lateral cortex

– Unstable

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OTA AO/ASIFClassification

• 31-A3– Two Part Fracture– Communution– Fracture enters the

lateral cortex– Reverse Obliquity

Fracture– Unstable

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Goals of Treatment

• Obtain A Stable Reduction

• Internal Fixation– Good Position

– Mechanically Adequate

• Permit Immediate Transfers & Early Ambulation

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Intra-Operative Positioning

• Hemilithotomy Position– un-injured limb

• Hip Flexed Abducted• Knee Flexed

• Scissors Position– un-injured limb

• Extended Hip

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Intra-Operative Flouroscopy

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Fracture Reduction

• Neck / Shaft Axial Alignment

• Translational Displacement

• Anatomic Reduction of Individual Fragments Not Necessary

• Reduction Maneuver– Traction

– Internal Rotation

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Implant Options

• Compression Hip Screw & Side Plate

• Intramedullary Sliding Hip Screw

• Calcar Replacing Prosthesis

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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

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Tip-Apex Distance (TAD)

• TAD – Strong Predictor of Cut

Out

• TAD <25mm– Failure Approaches Zero

• TAD >25mm– Chance of failure

increases rapidly

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Implant Options

• Compression Hip

Screw & Side Plate

– Controlled Impaction

of Fracture

– Higher Angles Greater

Tendency for

Impaction

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Implant Options

• Intramedullary Sliding Hip Screw– Decreased Implant

Bending Strain– Potential Percutaneus

Technique– Inter Troch Shaft– Reverse Obliquity– Pathologic Shaft

Fracture

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Implant Options• Calcar Replacing

Prosthesis– Indications

• Pathologic Fracture• Sever Osteopenia• Severe Communution• Rheumatoid Arthritis

– Benefits• Early Weight Bearing

– Problems• Greater Trochanter

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Special Fractures

• Reverse Obliquity

– Fracture in Lateral

Cortex

– Untable With Sliding

Hip Screw

– Im Nail or Fixed Angle

Device

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Reverse Obliquity Fracture

• DCS

• Blade Plate

• IM Nail

• Resist Medial Shaft

Displacement

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Cement Augmentation

• Severe Osteopenia

• Poymethyl Methacrylate (PMMA)

• Improves Screw Purchase

• Augment Deficient Medial Cortex

• Prevent Screw Cut Out

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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

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Failed Fixation

• Screw Cut Out

• Screw Barrel

Disengagement

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Salvage of Failed Fixation

• Angled Blade Plate

or Hip Screw

• Arthroplasty

– Calcar Replacement

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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

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Questions

?

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