6/23/2014

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Evaluation and Treatment of High Energy Proximal Femur Fractures

OVERVIEW • Introduction of Speakers - Objectives (2 minutes) • Injury Patterns, Evaluation - Patient Considerations Mike Gardner -- (10 minutes) • Operative Fixation: Nail - Dave Barei – (10 minutes) • Operative Fixation: Plate - Tim Achor – (10 minutes) • Problems and Complications - David Asprinio – (10 minutes) • Discussion/Cases/Q+A (20 minutes)

Michael J. Gardner, MD Washington University School of Medicine

St. Louis, MO

1. Femoral neck

2. Pertrochanteric

3. Subtrochanteric

High E Proximal Femur Fx

1) Intracapsular

Femoral neck fractures

1) Intracapsular

Implications:

• Synovial fluid bathed

• Endosteal healing

Femoral neck fractures

2) Blood supply

Femoral neck fractures

2) Blood supply

Implications:

• Tenuous

• Frequently disrupted

Femoral neck fractures

2) Blood supply

Disruption depends on :

• Displacement

• Superior exit point

Femoral neck fractures

2) Blood supply

Disruption depends on :

• Displacement

• Superior exit point

Femoral neck fractures

3) Age

Implications:

• Physiologic

• Activity level

• arthroplasty?

Femoral neck fractures

4) Occult in femoral shaft fractures

Femoral neck fractures

Femoral neck fractures

5) Radiography

• Hip frequently externally rotated

• Difficult to visualize fracture

• CT SCAN

• Pauwels’ Classification [1935]

0% non-union 13% AVN

8% non-union 30% AVN

12% non-union 35% AVN

Femoral neck fractures

Verticality Shear forces

Femoral neck fractures

6) Surgical timing

• Priortize REDUCTION and quality of surgery rather than TIME TO OR

Pertrochanteric fx

Pertrochanteric fx

1) “Simple” fx do not behave like geriatric fx

Implications:

• Plan for open reduction

• Avoid fracture table

Pertrochanteric fx

1) “Simple” fx do not behave like geriatric fx

Pertrochanteric fx

2) Radiography

• Define:

– Fracture lines

– Deformity

– FN extension

– Subtroch extension

• Stress views

Pertrochanteric fx

2) Radiography

• Define:

– Fracture lines

– Deformity

– FN extension

– Subtroch extension

• Stress views

• CT SCAN if question

Pertrochanteric fx

2) Radiography

Pertrochanteric fx

3) Search for subtrochanteric extensions that are able to be clamped

Pertrochanteric fx

3) Search for subtrochanteric extensions that are able to be clamped

Subtrochanteric fx

vs vs

Wide Spectrum

Subtrochanteric fx

• Classic deforming forces:

• Proximal segment

– Flexion

– Abduction

– ER

• Distal segment

– Adduction

– Shortening

Subtrochanteric fx

1) Radiography

• Quality AP and lateral to understand fracture and deformity

Subtrochanteric fx

1) Radiography

• Quality AP and lateral to understand fracture and deformity

• Proximal femur fractures are highly variable

• Different anatomic regions have different treatment implications

• Accurate understanding of fracture pattern is paramount

Summary

Thank You

6/23/2014

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Operative Fixation: Nail

David P. Barei MD, FRCSC Associate Professor Harborview Medical Center / University of Washington Seattle, WA barei@uw.edu

Evaluation and Treatment of High Energy Proximal

Femur Fractures

Disclosure

• Teaching Honoraria (AO)

• Synthes Consultant (implant design)

• Journal Reviewer

– JBJS-A, J Orthop Trauma, CORR

• AO Fellowship Committee

Institutional-UW Ortho-Research

• AO Spine North America

• AO-Sti ftung-ASIF Foundation

• Bank of America Foundation

• The Center, Orthopaedics and Neurological Surgeons

• Fidelity Investments

• Helena Orthopaedics Cl inic

• I l linois Orthopaedics & Hand Center

• Inland Orthopaedics of Spokane

• JMS Hand Associates

• Northwest Biomet, Inc.

• Paci fic Rim Orthopaedics

• Prol iance Surgeons, Inc.

• Prol iance Orthopeadics & Sports Medicine

• The Seattle Foundation

• Seattle Christian Foundation

• Si l icon Valley Community Foundation

• Simonian Sports Medicine Cl inic

• SKS Plastic Surgery

• Spectrum Research

• Synthes U.S.A.

• Synthes Spine Co.

• Washington Research Foundation

• Washington State Orthopaedics Association

• Webber Lawn & Yard Care

• National Institutes of Health (NIH)

• National Science Foundation (NSF)

• Veterans Affairs Rehabilitation Research and

• Development Service

• Orthopaedic Research and Education Foundation (OREF)

• A.O. North America

• Amgen, Inc.

• Bayer AG

• BioAxone Therapeutique, Inc.

• CeraPedics, LLC

• Chris topher Reeve Paralysis Foundation

• Depuy (Johnson & Johnson, Inc. )

• Foundation for Orthopedic Trauma

• Integra Lifesciences Corporation

• National Science Foundation

• Ostex International, Inc.

• Orthopaedic Trauma Association

• Paradigm Spine

• Smith & Nephew

• Synthes Spine Co.

• The Boeing Company

• US Army Research Office

• US Department of Education

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Definition

• Inferior border of lesser

5 centimeters

8 centimeters

Proximal 1/3 of femur

What are the problems/difficulties

with subtrochanteric fractures?

1. High mechanical stresses

2. Powerful muscular deforming forces on

the proximal segment

3. Complicated patterns

4. Relative avascularity

Maximal Compressive

Forces Medially (2-8 cm below lesser)

(1200 lb/in2)

High Tensile Forces

Laterally

High Mechanical Stresses

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Flexion

Abduction

External rotation

Deforming Forces

Infrequently confined to the

subtrochanteric region!

Proximal extensions into the

intertrochanteric region

Complex Fracture Patterns

Implant choices

Plates

Nails

Lateral fixed angle implant

Angled blade plate

Dynamic condylar screw

Lateral locked fixed angle implant (PFLP)

Sliding hip screw (DHS)

Piriformis start antegrade nail

Cephalomedullary nail

Trochanteric versus piriformis starting point

Head fixation (2 small versus 1 large fixation device)

(blade versus screws into head)

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Implant choices

Plates

Nails

Lateral fixed angle implant

Angled blade plate

Dynamic condylar screw

Lateral locked fixed angle implant (PFLP)

Sliding hip screw (DHS)

Piriformis start antegrade nail

Cephalomedullary nail

Trochanteric versus piriformis starting point

Head fixation (2 small versus 1 large fixation device)

(blade versus screws into head)

Why Choose A Nail?

Biomechanics

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Biomechanics of Fixation

Tencer et al, JOR, 1984

Plates (DHS, ABP) and Nails (Enders, Zickel, 3 locked nails)

Cadaveric specimens with and without bone contact

Plates stronger in torsion (50% vs 5%)

Both demonstrated bending ~80% of intact

Load to failure: Nails (300-400% body wt)

Plates (100-200% body wt)

Pugh et al, JOT, 1998

1st vs 2nd generation nails

Stable & Unstable

Increased stiffness in torsion & compression in 2nd

generation nails

Soft Tissue Friendly

What are the problems/difficulties

with subtrochanteric fractures?

1. High mechanical stresses

2. Powerful muscular deforming forces on

the proximal segment

3. Complicated patterns

4. Relative avascularity

Starting point errors with nailing

FAILURE TO REDUCE PRIOR TO

NAILING!!!

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• Allows indirect reduction

• techniques • (Medullary Splint)

• Good biomechanical properties

• Familiar technique

Correct Deformity Before Nailing!!!

Locked Antegrade Nail

Accurate Start Point Accurate Entrance Trajectory

Correct Abduction

Correct Rotation

Correct Flexion

Reduction • Proximal reduction (opposite of

femoral shaft fractures)

• Time limit for closed maneuvers!

• Supine vs. Lateral position

• Tools

• F-tool

• Spike pusher

• Schanz pin(s)

• Large clamp

• Intramedullary reduction

• Open reduction

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36 yo female fell while rock climbing

Accurate start point, accurate entrance trajectory, percutaneous and accurate reduction during reaming and nail insertion

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Open reduction, limited dissection, pointed reduction clamps and provisional

large diametered K-wires

Scolaro, Injury 2013

Open reduction, limited dissection, pointed reduction clamps and provisional

large diametered K-wires

Scolaro, Injury 2013

3 months postop

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Clamp Assisted Reduction of High Subtrochanteric

Fractures of the Femur. Afsari et al, JBJS, 2009

• 43 of 44 fractures united

• Percutaneous technique

• Excellent reduction

• Specific fracture patterns

• Successful technique

Open Reduction and IM Stabilisation of Subtrochanteric

Femur Fractures. Beingessner et al, Injury, 2013

• 56 patients treated with open reduction and IM nailing

• All fractures united

• Open reduction technique with limited dissection

• 98% united within 5° of anatomic in the coronal and sagittal planes

• No wound complications or infections

However…

• If you’re going to open a subtrochanteric fracture…

• Do it nicely!!!

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Cephalomedullary Nails….

Piriformis Recon Trochanteric Recon Trochanteric Hip Screw

Cephalomedullary Nails….

• Personally preferred for “lower” subtrochanteric fractures where there remains some diaphyseal shaped canal on the proximal segment – Helps with reduction

– Anatomic axis of the femur

• More commonly used in younger patients with higher quality bone

• Requires a slightly more anterior start point than typical piriformis nailing

Piriformis Recon

Piriformis Centromedullary Nail Start Point

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5 mm

Reconstruction =

Cephalomedullary =

Second Generation Nail

Piriformis Cephalomedullary Nail Start Point

Reconstruction =

Cephalomedullary =

Second Generation Nail

Piriformis Cephalomedullary Nail Start Point

Cephalomedullary Nails….

• Personally preferred for the “higher” subtrochanteric femur fracture ± intertrochanteric involvement

• Allows proximal locking to be more collinear with midcoronal plane of the femoral head/neck

• Can use the nail to aid in rotational reduction (built-in nail “version”)

• Requires strict attention to accurate start point to avoid varus malalignments

Trochanteric Recon

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Cephalomedullary Nails….

Trochanteric Recon

The tip of the trochanter, or even slightly medial to the tip, should be the entry site of choice for antegrade trochanteric

nailing of subtrochanteric fractures. The lateral starting point, even 2-3mm from the tip of the trochanter, is to be avoided

Recommendation

Trochanteric Cephalomedullary Nail Start Point

Piriformis Recon Trochanteric Recon

Cephalomedullary Nails….

• Single screw cephalomedullary nails – Typically demonstrate large proximal

nail diameters – Large single screw/blade proximal

femoral head/neck interlock

• Consider these as “geriatric”

fracture implants developed for unstable pertrochanteric fractures in that population

• Requires substantial bone removal in younger patients

Trochanteric Hip Screw

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Trochanteric Hip Screw

Trochanteric Hip Screw

Nails versus Plates

• Systematic review of outcomes of

extramedullary and intramedullary fixation

• Three Level I and Nine Level IV studies reviewed

– Grade B (fair) evidence shows

• Operative time reduced with IM fixation

• Fixation failure reduced with IM fixation

Kuzyk et al. Intramedullary vs. extramedullary fixation for subtrochanteric

fractures. (J Orthop Trauma 2009;23:465–470)

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Summary

• High force concentration region

• Notoriously difficult to treat

• Common deformities

– Flexion

– Abduction

– External Rotation

• Complex patterns with proximal extensions

– Trochanteric, piriformis, lesser, comminution

• IM Nails are suitable devices mechanically, but require attention to detail

– Anticipate the predictable deformities

– Reduce BEFORE nailing (using multiple tools and approaches)

– Don’t hesitate to open, but do it nicely

– Piriformis and trochanteric reconstruction nails are very effective but require accurate start points and entrance trajectories!

– Reserve medullary hip screw implants for physiologically older patients and fractures if possible

Summary

Thank You

HMC Trauma Faculty

Barei, Beingessner, Bellabarba, Benirschke, Dunbar, Ferguson, Firoozabadi, Hanel, Hansen, Henley, Kleweno, Sangeorzan, Smith, Taitsman

6/18/2014

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HIGH ENERGY HIP FRACTURES: PLATING TECHNIQUES

Timothy S. Achor, MD

UT Houston

Memorial Hermann Hospital

OBJECTIVES

• Discuss why high energy proximal femur fractures are different from geriatric hip fractures

• Discuss why plating these fractures is ideal

• Tips, tricks, pitfalls, recommendations

“NOT ALL HIP FRACTURES ARE CREATED EQUAL”

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HIGH ENERGY HIP FRACTURES MVC, MCC, FALL FROM HEIGHT

• Flexed

• Abducted

• Externally rotated

• Trend towards intramedullary nails for proximal femur fractures – Advantages:

• Biomechanical advantage

• Percutaneous technique

• Decreased OR time

– Disadvantages • Abductor mechanism

• Reaming

• Easy to introduce varus

NAIL VS PLATE?

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SURGERY

REDUCTION

IMPLANT

SURGERY

REDUCTION

IMPLANT

CLOSED

OPEN

PLATE

NAIL

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REDUCTION?

• Almost always OPEN

• You already have the incision

• Why disrupt endosteal blood supply and ream a hole in proximal femur?

TREATMENT OPTIONS:

PLATE SLIDING HIP SCREW

DYNAMIC CONDYLAR SCREW

PROXIMAL FEMUR PLATE

ANGLED BLADE PLATE

SLIDING HIP SCREW

• Intertrochanteric fractures • Subtrochanteric fractures* • Basilar neck fractures

• *NOT reverse oblique

FOR USE IN STABLE FRACTURES

CONTROLLED COLLAPSE

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OPTIONS

• Barrel length

• CCD angle

• Plate length

LONG

135 degree

2 – 4 hole

Tip-Apex Distance (TAD)

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DJ9235A 16

Dynamic Condylar Screw

–Transverse subtroch fractures –Short oblique subtrochanteric fractures –Long oblique subtrochanteric fractures

1. Roy Sanders and P.Regazzoni. “Treatment of Subtrochanteric Femur Fractures Using the Dynamic Condylar Screw.” Journal of Orthopaedic Trauma, vol. 3, no. 3, New York: Raven Press, 1989. 206-213.

Proximal Femur Locking Plates

– Anatomic, precontoured plate

– Multiple fixed angled screws

– MIPO (theoretical?)

– Submuscular

– Locking/cortical screws on shaft

+ / -

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ANGLED BLADE PLATE

Excellent historical track record Preferred implant for nonunions Technically challenging Relatively unforgiving 95 degrees – must be righteous

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BLADE PLATE?

• Simple fracture patterns • Patterns amenable to lag screws • Patterns amenable to compression • Patterns amenable to loading • Extension into neck • Extension into greater trochanter

• Lateral cortical read/apposition most important

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POST-OP PROTOCOL

• PROTECTED WEIGHT-BEARING X 8-12 WEEKS

• Monitor follow-up xrays closely

– May allow weight-bearing as early as 6 weeks

PITFALLS

• Malreduction

• Varus

• Varus

• Varus

• Using a plate when a nail might have been better

– Load-BEARING vs load-SHARING

• NOT TENSIONING THE PLATE!!!

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CASE 1

32 M s/p MVC

• Complaining of severe right hip pain

• +EtOH

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32 M s/p MVC

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• Fracture table?

• Open or closed reduction?

• Nail vs Plate?

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ARTICULATED TENSION DEVICE

“LOAD THE FRACTURE” “TENSION THE PLATE”

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64 M s/p MCC

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TREATMENT OPTIONS?

SAME OPTIONS?

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TREATMENT?

6 WEEK F/U

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58 M, ped struck

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TREATMENT OPTIONS?

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2 YEAR FOLLOW UP

22 M s/p MCC

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4 month follow-up

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IN CONCLUSION…

• Not all proximal femur fractures are equal – Age, Energy, Comminution, “Personality”

• DIFFICULT fractures to treat

• Treat each fracture individually with what

works best in YOUR hands

• Consider the 95 degree angled blade plate WITH the articulated tension device for simple, loadable fracture patterns.

THANK YOU

Timothy.S.Achor@uth.tmc.edu

6/19/2014

1

Evaluation and Treatment of High Energy

Proximal Femur Fractures

David E. Asprinio, M.D.

6/23/2014

Problems and Complications

10 MINUTES

• THESE ARE COMPLEX PROBLEMS

• NO UNIVERSAL SOLUTION

• OPTIONS

– Intramedullary fixation

– Blade plate fixation

– Proximal femur locking plates

– Compression hip screw

– 95 degree dynamic condylar screw

– External fixation

– Replacement arthroplasty

– Skeletal traction

Whatever is done needs to be done well

Many principles apply to prevention and treatment

Avoiding problems and complications • Evaluate the patient and radiographs

– Consider co-morbidities and other injuries

• Need a plan and a backup plan

– Need to be familiar with multiple modalities

– Know what can be done and know your limitations

• Reduction is critical

– Must achieve and maintain

– Intramedullary devices don’t achieve reduction

– Fixed angle devices may achieve reduction

however placement is critical

• Avoid unnecessary soft tissue dissection

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RS 1/24/07

INTROPERATIVE TRACTION

RS 1/25/07

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VM 76 y/o male 3/9/12

GD 81 y/o male 4/29/14

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GD 4/30/14

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GD 6 weeks

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DA 26 y/o male 3/17/12

TRACTION IN OR

Can’t overstate value of

femoral distractor and

shanz pins as joysticks

DA 3/17/2012

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DA 6 months

JM 65 y/o male

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When complications occur

• Evaluate the patient and radiographs

– Why did failure occur?

• Mechanical

– Reduction

– Choice of implant

– Placement of implant

• Biological

– Infection

– Osteoporosis

– Metabolic bone disease

• Patient non compliance

Treating complications

• Address prior deficiencies in treatment

• Need plan and backup plan

– Need to be facile with multiple modalities

– Know what can be done and know your

limitations

MUST ACHIEVE REDUCTION

CORRECT VARUS AND FLEXION ABNORMALITIES

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WL 51 Y/O MALE

10/2013

8 months

10/24/13

ROH, compression plating with restoration

of alignment, allograft, stem cell autograft

WL 6 months FWB without pain

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ES 88 y/o male 12/2013

ES 2/25/14 2months

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Summary

• It is better to avoid than treat complications

• Preoperative planning is critical

• Have multiple treatment options available

• Optimizing the mechanical and biological

environment will increase the likelihood of

successful treatment