Femur Fractures: Subtrochanteric to Supracondylar

8/19/2019 Femur Fractures: Subtrochanteric to Supracondylar

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2016 Annual Meeting

Instructional Course

Lecture Handout

Course Number: 250

Course Title: Femur Fractures: Subtrochanteric to Supracondylar

Location: Room W307C

Date & Start Time: Mar 2 2016 1:30 PM

INSTRUCTORS WHO CONTRIBUTED TO THIS HANDOUT:

Robert F Ostrum, MD Paul Tornetta III, MD

Philip R Wolinsky, MD


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AAOS – Femoral shaft fractures: Subtrochanteric to Supracondylar

ICL 250

IM Nailing of Subtrochanteric femur Fractures

Robert F. Ostrum, M.D.

University of North Carolina – Chapel Hill

• High compression/tension stress area with cantilever bend

• Deformity: flexion, external rotation, and abduction of the small proximal

fragment making IM nailing difficult

• Evaluation of fracture

o Piriformis fossa

o

Greater trochantero Lesser trochanter

• Surgical Planningo

Supine

o Lateralo

Fracture Table

• Implant Choiceso

Piriformis Nail

o Trochanteric Nail

• Problems

• Incorrect starting point

• Lack of reduction while reaming

•

Poor trajectory of guide rod

• IM nail with deformity


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Wrong Right

For IM nailing:

Reduction during reaming and the correct starting point are the keys to

optimal results

Operative tricks

• Use instruments, clamps to reduce flexion and abduction

deformities prior to reaming

• Start piriformis foss nail in line with shaft, guide pin NOT

pointing towards the lesser trochanter

• The trochanteric insertion site should be just MEDIAL to the

tip of the trochanter

• Skin incision for IM nailing is NOT at the tip of the trochanter

but rather 5-8 cms proximal and in line with the shaft

• MUST have a way to assess LENGTH and ROTATION


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References

1. Starr AJ, Hay MT, Reinert CM, Borer DS, Christensen KC.

Cephalomedullary nails in the treatment of high-energy proximal femur

fractures in young patients: a prospective, randomized comparison of

trochanteric versus piriformis fossa entry portal. J Orthop Trauma. 2006

Apr;20(4):240-6.

2. Perez EA, Jahangir AA, Mashru RP, Russell TA. Is there a gluteus

medius tendon injury during reaming through a modified medial trochanteric

portal? A cadaver study J Orthop Trauma. 2007 Oct;21(9):617-20.

3. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of theeccentric starting point for trochanteric intramedullary femoral nailing.

J Orthop Trauma. 2005 Nov-Dec;19(10):681-6.

4. French BG, Tornetta P 3rd. Use of an interlocked cephalomedullary nail

for subtrochanteric fracture stabilization. Clin Orthop Relat Res. 1998

Mar;(348):95-100.

5. McConnell T, Tornetta P 3rd, Benson E, Manuel J.

Gluteus medius tendon injury during reaming for gamma nail insertion. Clin

Orthop Relat Res. 2003 Feb;(407):199-202.

6. Streubel PN, Wong AH, Ricci WM, Gardner MJ.

Is there a standard trochanteric entry site for nailing of subtrochanteric femur

fractures. J Orthop Trauma. 2011 Apr;25(4):202-7.


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1/2/16

2

“A” Fractures•

Options

•

Nail

! Enough room for

locking screws

• Plate

! Fixed angle


Options

•

Nail

! Enough room for

locking screws

• Plate

! Fixed angle


Options

•

Nail

! Enough room for

locking screws

• Plate

! Fixed angle

“B” Fractures

•

Shear fractures

• Stabilize

! To the rest of the joint

! To the shaft

! Lag screws

! Buttress

! Antiglide

“B” Fracture Percutaneous ORIF

B Fracture “C” Fractures• Combination of “A” and “B”

• Principles:

! Restore joint …. C A

! Stabilize the metaphysis to theshaft

! Complexity of joint determines

options for stabilization

Simple Joint Injury

• Lag screws for the joint

•

Metaphysis

! Nail

! Plate

• Fixed angle


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1/2/16

3

Supracondylar Fractures• Short IM nails (GSH type)

• Compared to fixed angle:

! Equal to varus load

! to bending and torsion

• Failure mode: shaft fracture

through proximal screw hole

IM Nails• Advantages

! Midline incision

• Indirect reduction

•

Minimal stripping

• Blood loss

! Reaming distributes bone graft

! Metaphyseal comminution irrelevant

IM Nails• Disadvantages

! Intraarticular starting point

! Large intercondylar portal ?

! Locking screws may be through

coronal fracture lines

! Stress riser through unfilled

holes

Indications

• Metaphyseal injuries > 4 cmfrom notch (type A)

• Minimal intraarticular extension

• Large condylar fragments thatcan be fixed with lag screws(C1)

26 Year Old MVA S/P Nailing

Grade 3 Open C2 Fx Lag Screws + Nail Final


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1/2/16

4

Nonunion….BGTechnique• Midline incision

! Poke hole vs arthrotomy

• Reduce and lag intercondylarfracture first

• Indirect reduction of the

metaphysis

Technique• Radiolucent table

• Bolster

• Distractor ?

• Portal

• Direct up shaft on AP and lat

• Over-ream 1.5 mm

•

Lock at lesser trochanter

Incision Free Medial Side Arthrotomy

Portal Location

B l u m e n s t a t ’ s

T r o c h l e

a r G r o o

v e

Canal Location Nail Curvature


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1/2/16

5

Portal Location Portal Location

Even 1 mm

Proud is Bad!!

Flexion Arc

Avg arc 17°

34° - 51°

AP View AP View AP View

Physiologic

Valgus

Starter Reamer Distally Lock Check Length


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1/2/16

6

Proximal Locking• Level of the lesser trochanter

• Safest level

! Nerves cross

! Artery 1 cm medial

• Just at the piriformis

Example Nailed.. Too High!!

Watch Sagital AlignmentBlocking Screws

Blocking Reduction! Finals Results• Lucas 1993! 25 Fractures (9 open)

! Type A (6), type C (19)

! 6 Acute bone grafts

! Avg. ROM > 100°• 6 Required manipulation

! 1 Short, 1 12° varus

! 1 Late intraarticular infection

! Two iatrogenic fractures


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1/2/16

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Results•

Iannacone 1994! 41 Fractures (22 open)

! Type A (19), type C (22)

! 80% Union by 4 months

! Delayed / non union due to injury

! Nail failure (6.4 screws in 11mm nail)

! 87% > 90° Motion

! All < 5° VV and < 10° AP angulation

Fractures Above TKA• Incidence 0.5% - 2.0%

• Bone quality

• Distal femoral notching

• Arthrofibrosis

Fractures Above TKA• Requires 12 mm intercondylarregion

• Contraindicated if closedintercondylar box

Technique

•

Midline incision

! Slightly larger than standard

• Obtain reduction

• Ream 1.5 mm over nail size

• Statically lock

• Postop early motion

74 Year Old Woman Treatment

Results

• Union in > 90%

• Time to union < 12 weeks

• Motion compared withpreinjury

Plates

• Indications

! Complex Intraarticular

! Below THA

! Low A type fractures

! Bowed femora

! Distal 1/3 fractures

“Old” Plate Case…


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Deformity Intraarticular Fragment Articular Reduction

Articular Reduction

AP VIEW

LATERAL VIEW

95°

Planned Axis

Affix to Screw Reduction Fluoro…


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6 Weeks 4 Months Complex Joint Injury• Joint has comminution

•

Posterior fragments

• Will not accept nail

! Hoop stresses

! Poor fixation of the locking

screws

Complex Joint Injury

• Plate is treatment ofchoice

• Fix joint (screws)

• Connect to shaft

• Fixed angle!!

! Prevents varus collapse

Problems..

• Locked plates:

! Fixed angle periarticular

segments

! Indirect reductions

! Biologically friendly

! Osteoporotic bone

• Different failure modes

Problems…

• Locked plates:


segments



! Osteoporotic bone


Problems

• Locked plates:


segments



! Osteoporotic bone


Old Ideas…New Tricks?

• How can we improve?

• Plate contours

• Hole configuration

• Screw direction

• Reduction techniques

• Instrumentation

When do we need them?• Periarticular fractures

! With metadiaphyseal

dissociation

•

Poor bone quality! Osteoporosis

! Nonunions

! Revision surgery


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Locked Plating…• Intraarticular fractures

• Joint fixation

! Outside plate

! Metadiaphyseal reduction

• Extraarticular fractures

• Around knee implants

Incision Deep Incision

VisualizationScrews Around Plate Lag Screw Position

Lag Screw Position Outrigger Metadiaphyseal Reduction


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1/2/16

12

Instrumentation• Simple

• Keep angles correct

• Appropriate guides

• Limit pieces

• Screw options…

Slide in Plate Provisionally Fix

Place Fixation Final AlignmentHealing is Good

• Grade 3A fx at 10weeks

• Good principles

• Indirect reduction

Worst Problems

Grade 3 open

Initial Treatment Delayed Fixation


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1/2/16

13

Delayed Grafting Delayed GraftingLateral Postop

5 Months… Periprosthetic Fractures Periprosthetic Fractures

Periprosthetic Fractures Periprosthetic Fractures Periprosthetic Fractures


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1/2/16

15

SMFA

0

5

10

15

20

25

30

35

40

45

3 Months 6 Months 12 Months

SOLVED So Far…• 143 Patients (target 160)! 75 Nails

! 68 Plates

• Adverse events

! 52 Total

! 25% for both nail and plate

! 20 Device related

Alignment

Valgus > 5° Varus > 5°

Nail 9 (12%) 0

Plate 14 (20%) 1 (2%)

Alignment

Valgus > 5° Varus > 5°

Nail 9 (12%) 0

Plate 14 (20%) 1 (2%)

ComplicationsNail Plate

Painful Implant2 Nail

8 Screws8 Plates(3 out)

Loose 3 2

Nonunion 0 2

Infection 2 1

Arthrofibrosis 0 1

Adverse Events• 5 DVT, 1 Death

• 20% Both groups

• Revision

! 5% Nails! 8% Plates

• Hardware removal! 15% Nails (90% screws)

! 10% Plates

Case Example Postop


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1/2/16

16

3 Weeks

Nail!!! Multitrauma..Open

14 Months, New Pain CT Intraop

Plate Final Summary• Nails…

! Metaphyseal comminution

! Long shaft extension

! Elderly patients

! Minimal intraarticular extension

• Large condylar fragments


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Femur Fractures: Subtrochanteric to Supracondylar

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