Hip Fracture: A Surgeon’s Perspective

Mellick J Chehade

PhD, MBBS, FRACS, FAOrthA

Orthopaedic Trauma Surgeon

University of Adelaide

Royal Adelaide Hospital

Declaration of Interest

I declare that in the past three years I have:

• held shares in: Nil • received royalties from: Nil • done consulting work for: Nil • given paid presentations for:Nil • received institutional support from:

Stryker South Pacific Zimmer

•other AO Foundation

OTC Foundation

Signed:

Outline

Background

Decision to operate

Timing

Implant options and biomechanics

Surgical exposures

Rehabilitation decisions

Follow-up

Outcome measures and Audit

Background

Osteopenia complicates both fracture treatment and healing Internal fixation compromised

Poor screw purchase

Increased risk of screw pull out

Increased risk of non-union

Screw-Bone Interface?

Osteoporosis – Challenge

Changes in cortical bone

Decreased thickness

Increase of bone diameter to maintain bending stiffness

CT cross sections of the femur

Changes in cortical bone

Increased haversian canal areas (lacunae formation)

Increased weakness and predisposition to

low-energy fractures

Changes in cancellous bone

Less and thinner trabeculae with fewer, often broken

interconnections

Courtesy of Ralph Müller

Swiss Federal Institute of Technology, Zürich

Young, normal lumbar spine Osteoporotic lumbar spine

Changes in cortical and cancellous bone

78-year-old male, normal bone 72-year-old male, osteoporotic bone

Changes in cancellous bone

Reduced cutout resistance and bone voids

Decision to operate

Need to carefully consider and plan for

options early - this includes

NON OPERATIVE MANAGEMENT

Informed Consent

Medical condition – fitness for surgery

Cognition

Rehabilitation potential

Advance directives

Family

Palliative options-facilities

End of Life Issues

Advance directives

Treatment dilemmas

Family conflicts

Costly (US 27% final year)

Inhumane

Timing

Ideally ASAP

Realistically < 36 hours

“daylight”

end of day after admission

Issues

Medical Optimisation

Anaesthetist requirements (ECHO)

Theatre / Surgeon availability

Getting Consent

“Quality Systems” vs “KPI’s” (clinician vs administrator)

Implant options and

biomechanics

Changes in cortical bone

Decreased thickness

Less “working length” of implants

Courtesy of Stephan Perren

Implant characteristics—biomechanics

• Conventional screws

• Screws loaded in tension

• Plate-bone friction

• Compression at fracture site

Locking head screws (LHS)

• Screws loaded in shear

• No compression of fracture

Clinical advantages in osteoporosis

• LHS cannot be over-tightened

• Higher resistance against bending forces

• No secondary screw loosening

• Suitable for minimal invasive procedures

Specific implant characteristics—blades

Increased bone-implant interface by blades instead of

screws—contact area of +53%

Specific implant characteristics—augmentation

Increased bone-implant

interface by augmentation

around the inserted screws

Hip fractures Trochanteric (extra-capsular) vs Neck (Intra-capsular)

https://www2.aofoundation.org/wps/portal/surgery?showPage=diagnosis&bone=Femur&segment=Proximal

Trochanteric Anastomosis

anastomotic ring of arteries

found in the trochanteric fossa

and around the neck of the

femur.

Formed by the union of

branches from:

1) medial circumflex femoral

artery.

2) ascending branch of the

lateral circumflex femoral artery.

3) inferior gluteal artery.

4) superior gluteal artery.

1 2

3

4

Arteries & nerves of gluteal region

Hip Fractures

Trochanteric fractures

Extracapsular (well vascularized)

Region distal to the neck between the trochanters

Calcar femorale

Posteromedial cortex

Important muscular insertions

Trochanteric Fractures

Pertrochanteric

stable

Pertrochanteric

unstable

Intertrochanteric

reverse oblique

Nails and Plates

Basic IM Nailing Workshop -City Month #, 201#

Basic IM Nailing Workshop -City Month #, 201#

DHS

Rarely “anatomical”

(Rao et al, 162 unstable #’s –

90% medial displacement

Frohlich & Benko, 182 #’s –

47% > 1cm shortening

Associated with pain on W/B

Hip Fractures Femoral neck fractures

Intracapsular location

Vascular Supply

Medial and lateral circumflex vessels anastamose at the base of the neck

blood supply predominately from ascending arteries (90%)

Artery of ligamentum teres (10%)

1,2 Compression Screw

3,4 Austin Moore

Garden Classification

Arthroplasty Options Hemi vs Total

https://aoanjrr.dmac.adelaide.edu.au/

Surgical exposures

Approaches (abductors/stability v exposure)

Posterior

Lateral

Anterior

Surgical experience

Equipment

Available options

Hoppenfeld surgical exposures 2nd edition

Lateral approach

59

86 yo – living in nursing home

post op

6/12 post op

60

6/52 post surgery 1 year post surgery

PROTECTED WEIGHT-BEARING:

SAFETY

OR SCIENCE FICTION?

Protecting (Fooling) Who?

269% max

211% max

156% max

187% max

99% max

187% max

98% max

Peak loads (% Body Weight)

Normal

Walking 2.5 – 3 x

Sitting/ Standing 2 – 2.5 x

In bed

Sitting up in bed 1-5 – 2 x

Pelvic tilt/pull up 1.5-1.8 x

FWB with aids 0.8 -1.8 x

Stumbling

Rehabilitation

‘…the realisation of optimal function despite residual disability or the development of a person to the fullest physical,

psychological, social, vocational and educational potential consistent with his or her physiological

or anatomical impairment and environmental limitations…”

Follow up

Extremely Variable

Private vs Public

Independent living vs Nursing Home

Remote location

Patients magically find their own way

back when needed

By Whom?

GP

Orthopaedic Surgeon

Geriatrician

Rehab Physician

Case coordinator (nurse?) - Multi_D links

Nobody

RAH Remote/Virtual Clinic

Research assistant Nurse?

Community Xrays

Teleradiology

Asynchronous Orthopaedic Review

Customised (Patient Centred Responses)

Hip fracture Outcomes From Virtual Clinic

Includes:

Baseline data

Mortality

Complications

Surgical data

Patient important outcome factors:

Residence

Pain

Mobility

Function

Hip Pain

Percent of Patients Reporting No Hip Pain

0

10

20

30

40

50

60

70

80

90

100

DHS Short Gamma nail Long Gamma nail

Comparisonof 6 month dataacross devicesp=0.189Chi-square test

6 weeks

3 months

6 months

Pre-injury

% o

f p

ati

en

ts a

ss

es

se

d

Percent Return of Function

% Return of Function After Hip Fracture(median IQR)

0

25

50

75

100

DHS Short Gamma nail Long Gamma nail

Comparisonof 6 month dataacross devicesp=0.074Kruskal-Wallis test

6 weeks

3 months

6 months

% r

etu

rn o

f fu

nc

tio

n

Return to Home

Percent of Patients Living at Home at Time of InjuryWho Are Living at Home at Follow-up

0

10

20

30

40

50

60

70

80

90

100

DHS Short Gamma nail Long Gamma nail

Comparisonof 6 month dataacross devicesp=0.123Chi-square test

3 months

6 months

% o

f p

ati

en

ts a

ss

es

se

d

Percent Early Deaths

29%

18.6%

14.3%

10.5%

0

5

10

15

20

25

30

35

Within 6 months Within 12 months

Perc

en

t o

f h

om

e r

esid

en

ts

Male

Female

1 yr mortality for community ambulating males matches all patient

mortality (29%) including palliative cases and nursing home residents

Percent Deaths Within 1 year Home Vs Nursing Home

57%

29%

43%

14.3%

0

10

20

30

40

50

60

Own home Nursing home

Perc

en

t o

f h

om

e r

esid

en

ts

Male

Female

Biggest gender difference in mortality is in those living at home at the time

of injury (community ambulators)

Summary

Challenging

Optimising biomechanics to minimise immobility and maximise function

Holistic orthopaedic surgeon

Bone is connected to a human being

Good outcomes require successful management at EACH & EVERY STEP of

the “patient journey”

COLLABORATION

DATA COLLECTION

EDUCATION

The Australian Musculoskeletal Education Collaboration: AMSEC

www.amsec.org.au