Is the biomechanical problem of trochanteric fracture solved?

Transcription

1 Is the biomechanical problem of trochanteric fracture solved? Dr Gabor Szabo Josa Andras Teaching Hospital Nyíregyhaza, Hungary

2 Naumov et al: Per and subtrochanteric fractures Magyar Traumatológia, Ortopédia, Kézsebészet,Plasztikai Sebészet, local complications (n=316) 6,4% I. B. Schipper et al: Randomised comparison of the gamma nail and the proximal femoral nail The Journal of Bone and Joint Surgery, 2004;86-B: mechanical complications : PFN (n=221): 57 (25%) gamma-nail (n=213): 53 (24,8%) postoperative complications: PFN: 31 (14%) gamma-nail: 20 (9,4%) Badó et al: Experiences with Gamma nailing Magyar Traumatológia, Ortopédia, Kézsebészet, Plasztikai Sebészet, local complications (n=621): 6,7% (short nail) S. Pietruschka et al: Erfahrungen mit dem Gamma-Nagel Einfluss des Verzichtes auf die distale Markraumerweiterung mechanical complications (intraoperativ): 15% postoperative complications: 5,9%

3 605 proximal femoral fractures ( ) PFN-A other proximal femoral nail 494 (81,6%) 111 (18,4%) 15% 38% 24% 29% 47% 47% A1 A2 A3 A1 A2 A3

4 No. of cases <20 év év év év év év év Patients ages (year) év év év< PFN-A egyéb Other trochanter-szeg nail

5 Intraoperativ complications (n=605) PFN-A (n=494) other nail (n=111) problems with the inserter s removal 1 (0,2%) 0 distal lockin failure 1 (0,2%) 3 (2,7%) Intraoperativ fractures 1 (0,2%) 1 (0,9%) reposition failure (varus) 7 (1,4%) 2 (1,8%) Postoperativ mechanical complications cut out of the head 2 (0,4%) 1 (0,9%) distal cut out and fracture 0 1 (0,9%) head perforation 0 1 (0,9%) distal screw slide out 1 (0,2%) 0 distal screw break 0 1 (0,9%) nail break 0 1 (0,9%) slide out of the component from the head 1 (0,2%) 0 periimplantatoric fracture 6 (1,2%) 1 (0,9%) reoperation because mechanical problems 4 (0,8%) 2 (1,8%)

6 Implant specific complications PFN-A (n=494) other nail (n=111) intraoperativ 3 (0,6%) 4 (3,6%) postoperativ 8 (1,6%) 7 (6,3%) summ 11 (2,2%) 11 (9,9%)

7 Why do we like? Reduced the complication rate to 20% (from 9,9% to 2,2%) in our department Precise instruments (easy and fast technique) Reliable stability in osteoporotic and unsable cases Minimally invasive

8 What is the secret? The antirotation blade Anatomical design Dinamic fixation between nail and blade Flexible nail tip

9 Implant specific complications, case reports, tips and tricks with PFN-A Dr Gabor Szabo Josa Andras Teaching Hospital Nyíregyhaza, Hungary

10 Comminuted shaft frecture with PFN-A, after 3 months good callus formation, no dislocation, full weight bearing. After 2 years: IMPLANT REMOVAL??? y.o. polytrauma patient postop.

11 2. 67 y.o. male pertrochanteric fracture with healed PFN-A For adekvate trauma shaft fracture under. Threated with PFN-A long and healed after dinamization.

12 3. 82 y.o. female pathological fracture (pulm. cc. metast.) with PFN-A.

13 4. Reposition failure (varus) & implant malposition

14 Patient positioning Reduce the fracture Determine the inserion point well! Avoid the forced internal rotation!

15 5. Malposition of the blade 1. spongiosa impactation Antero-central position of the blade with poor bone quality. Cranial migration of blade and cut out. Healing after reoperation with PFN-A and spongiosa impactation.

16 With good bone quality and no severe insatbility = CENTRAL POSITIONED BLADE Poor bone quality and/or severe insatbility = POSITION IN CLEVELAND ZONE (postero-inferior)??? The rotation force increases with excentral placed blade!

17 Central blade position + No drilling for the blade, only open the lateral cortex

18 6. Malposition of the blade The blade is subchondral, good bone healing with no femoral head perforation

19 7. The sipral blade s nut had to be broken down with the inserter because they stucked together. 3 weeks after the moved away sleeve was extracted, the fracture healed in varus position.

20 Untighten all and in fully locked position the inserter will be able to taken over

21 8. The screwdriver s tip can be broken into the endcup.

22 After the synthesis is stabil, more space available at the trochanteric region if you adducate the hip Canulated technique is not necessary

23 9. The tip of the drill bit broke into the bone

24 Alwalys check the tighten before distal locking! Change the sleeves (dynamic static) and it will lead your new drill bit belongside the broken piece, so after this you will be able to pick it

25 10. Lateral femoral neck fracture with PFN-A GOOD or BAD INDICATION???

26 Thank you for your attention!