ICUC Paper. The treatment of trochanteric fractures revisited: Pietro Regazzoni, Alberto Fernandez, Dominik Heim, Stephan M. Perren.

Transcription

1 The treatment of trochanteric fractures revisited: Pietro Regazzoni, Alberto Fernandez, Dominik Heim, Stephan M. Perren September 2016 An optimal treatment of hip fractures is crucial because of the great number of involved patients suffering as well as for the large health care costs generated. The following examples focus on clinical problems and propositions to avoid common errors. Furthermore, the cases illustrate that understanding the specific problems of the individual fracture is far more important than the choice of the implant. Unfortunately, scientific papers often put too much emphasis on the advantages and disadvantages of different implants and do not discuss the problem of different fracture pattern. The latter has a large impact on specific procedures on the one hand and on the other hand on implants selected to provide the specific function. Simple guidelines (Reference 9) alone, however well formulated, cannot be sufficient; practical examples must illustrate the problems in detail using drawings, video clips and particularly intraoperative images. This can be easily found using digital learning tools. Frequent problems in the treatment of trochanteric fractures are hereinafter illustrated by a series of cases which show that whilst specific problems of different fracture pattern might not be solved with one single technical tool. On the other hand, similar fractures can be successfully treated by different implants. In any case technical skills are crucial. The following cases are mainly extracted from the ICUC App database Implant complications can occur after the use of any implant. Cut-outs can occur, if the implant is not correctly placed in the femoral head. (Fig. 1) Using non-telescoping implants bears the risk of implant fatigue. Therefore, both nails and hip screws allow a controlled impaction during weight bearing (Fig. 2). The centro-medullary (more medial) position of nails is an advantage, but fatigue can also occur after nailing (Fig. 3). Fig. 1: Cut-out of implants: If implants are not correctly placed in the femoral head, there is a great risk of cut-out. The superior and the anterior hemisphere of the head have to be avoided. On the left side a gliding Hip Screw, on the right side a nail. 1 The ICUC database is freely accessible by downloading ICUC App from the Apple App Store ( The single cases are individually identified through case ID. The ID allows simple searching with the ipad s Spotlight function. We recommend using this database because it provides a wealth of information with all critical steps in surgery and radiology, supported by animations and expert comments. (Reference 4) 1

2 Implant fatigue can also be observed with any type of non-telescoping implant following cyclic bending stresses, if the fracture does not heal before a critical number of cycles is reached. Fig. 2: Fatigue fracture of a rigid implant: The implant (blade plate) fails before consolidation of the fracture because of lack of unloading bone support. (see also Fig. 15) Fig. 3: Fatigue fracture of a nail: 70 year old patient ICUC App ID: 31-PC-740. Healing after reoperation with new nail. (Reference 4) 2

3 2. Wrong nail-entry-point and Varus mal-reduction or medial displacement of the head-and-neck fragment can occur after insufficient reduction maneuvers or when a nail is introduced through the fracture. This is due to the fact that the medial part of the greater trochanter which might be attached to the proximal fragment is much harder than the lateral part of the greater trochanter. There is therefore a tendency for the opening instrument to glide laterally into the fracture, if the sleeve is not maintained in the correct position at the tip of the trochanter during the opening of the canal for the nail. This can be avoided by a special aiming device (Fig. 4). Fig. 4: Curved protection sleeve ICUC App ID: 31-PS-042, ID: 31-PC-610 (Reference 4) The curved sleeve is maintained in place and avoids lateral displacement of opening awl. According to fracture type the hard bone of the medial part of the greater trochanter attached to the head-and-neck fragment can be also reamed. Fig. 5: Entry point too lateral: These ICUC App cases show that nails are entering too far lateral (through the fracture). Fortunately, the fractures healed, despite the varus displacement of the proximal fragment due to the wrong entry point. 3

4 3. The rotational instability of the head-and-neck fragment, a relevant pathophysiological entity, has to be recognized and treated with an additional anti-rotation device. The use of a trochanteric buttress plate alone does not avoid rotation of the proximal fragment during walking and moving the hip. Fig. 6: Rotationally unstable head-and-neck fragment in a trochanteric fracture Rotation of the proximal fragment in the absence of a second stabilizing element. The correct use of a trochanter stabilizing plate with an additional screw through the plate is shown in Fig. 6 and in ICUC App: Proximal femur / Reference Cases / DHS + TSP (Reference 4) 4. Poor reduction and potential additional fragmentation of the greater trochanter and lateral cortex can worsen the outcome. The lateral cortex of the proximal femur and especially the greater trochanter needs particular attention: further fragmentation of the tip or the lateral cortex during the reaming and introduction of a nail has to be avoided. Fig. 7: Fragmentation of lateral wall during nail insertion. ICUC App ID: 31-PC

5 Proximal dislocation of fragments of the greater trochanter can lead to a relevant disability, i.e. abductor insufficiency (Reference 3), which has therefore to be prevented (ICUC App ID: 31 PC 640, ID: 31 PC 485). Fig. 8: Dislocation of the tip of the trochanter Function of the abductors can be disturbed by dislocation of the tip of the trochanter (Fig. 8). The use of a tension band for fixation of small fragments can sometimes be useful. Alternatively, a screw-plate and additional buttress plate can be considered. ICUC App: Proximal femur /Reference Cases / DHS + TSP (Reference 4) 5. Incomplete reduction and maintenance of reduction during nailing. Nailing should never be started, if the reduction of the fracture is insufficient and not maintained correctly, for example: protruding lateral spikes of the proximal fragment are very disturbing and can require revision surgery (Fig. 9). Fig. 9: Disturbing lateral spike of proximal fragment. Nailing started before sufficient reduction. After the introduction of the nail a correction of the reduction is no longer possible. To improve reduction and maintain it MIO cerclages are useful for certain fracture types (Reference 6). See also Fig

6 6. Cerclage wires or cables to improve and maintain reduction wires or cables are very useful (Fig. 9, 10, 11) Cerclages have come into disrepute because of the presumed vascular damage they should cause. Additional damage during the cerclage placement can be minimized using an appropriate instrument, the MIO cerclage passer (Reference 4, 6). Fig. 10: Reduction of lateral spike using a cerclage The reduction is improved before nail introduction using a cerclage (left image). Details of the case ICUC App ID: 31-PE-779 (right image) (Reference 4) 7. Minimal opening to help reduction is preferable to long lasting closed fiddling ending with unsatisfactory reduction. Fig. 11: Reduction of sub trochanteric element with a cerclage. Only a minimal additional opening is necessary to place the cerclage, resulting in optimal reduction (for details of the procedure ICUC App (Reference 4)). A minimal additional access is often better than a lengthy closed fiddling 6

7 8. Trochanteric buttress plates should always be used with an anti-rotation screw. Fig. 12: Correct use of Hip screw Here a buttress plate and anti-rotation screw are used, whereby the screw is inserted through a plate (Reference 1) for details of the case ICUC App ID: 31-PS-538 (Reference 4). The anti-rotation screw has to be placed through the plate to avoid perforation into the joint during telescoping (Fig. 13) Fig. 13: Wrong use of anti-rotation screw under the buttress plate Progressive joint penetration of anti-rotation screw (placed under the plate) during telescoping. For details of the case ICUC App ID: 31-PS-689 and ICUC Proximal Femur, Expert opinion, Trochanter stabilization (Reference 4) 7

8 9. Surgical technique and correct use of different implants is crucial and much more important than implant choice. Complex trochanteric fractures can be technically very demanding and should not be left to unexperienced surgeons ICUC Proximal Femur, Reference Cases, DHS +TSP (Reference 4) Fig. 14: Different implant choice for similar fractures with good healing. In experienced hands similar fractures can be treated with many different implant types with similar results Fig. 14 (Reference 2) It is not the choice of the implant (nail or plate) that determines the outcome, but rather the way the implants which are used, i.e. the problems of the given fracture are solved. In the image on the right, details of the ICUC App case ID: 31-PE-682 (Reference 4). Fig. 15: Implant fatigue after third unsuccessful surgery. Angled blade plate for a complex case with many previous operations. Active woman of 63 years. First operation: cut-out after wrong use of implant (Fig. 6) Second operation: cut-out after change from plate to nail with wrong implant placement in femoral head (Fig. 1). Third operation with no-telescopic implant and implant fatigue (Fig. 2) Fourth operation: consolidation after change of blade plate. Joint replacement avoided in patient of only 63 years. The use of blade plates, however technically demanding, is useful for certain (revision) cases and the technique should not be forgotten. ICUC App ID: 31-PE-475 (Reference 4) 8

9 Discussion and an answer to Guidelines published as "Recommendations on Hip Fractures, Eur J Trauma Emerg Surg: 2016, 42, (Reference 9) A study group of the European Society for Trauma and Emergency Surgery, formed in 2014, published ESTES recommendations on proximal hip fractures. Both femoral neck and pertrochanteric fractures are discussed. The authors included aspects of diagnostics and preoperative workup as well as operative therapy and postoperative treatment. The arguments for pre- and postoperative treatment are well taken. Their recommendations for the surgical treatment of neck fractures using the Garden classification can easily be accepted: internal fixation for non or slightly displaced fractures and hemiarthroplasty or THR for displaced types according to age and general conditions. Their recommendations for pertrochanteric fractures (using the AO classification) are compliant with the available literature (Reference 5, 7, 8) but unfortunately, are too generic and need a more differentiated approach: - gliding hip screws for stable fractures (A.1 and A2.1) - antegrade intramedullary nails for unstable fractures (A 2.2, A 2.3 and A3) Considering the great spectrum of fracture pattern and the big number of problems a slightly more differentiated disquisition, using intraoperative images might be useful (see also previous cases). Summary: - An optimal treatment of trochanteric fractures is crucial because of their frequency and the high health care costs they generate. The extensive literature often deals with implant choice instead of the problems of the various fracture types. Similar fractures can be successfully treated with different implant types, if used with adequate technical skills. Complex fractures remain technically difficult and should not be left to inexperienced surgeons, even if they are frequent. - Simple guidelines with an accent on implant selection are not sufficient. Illustrated clinical examples, focusing on problems and possible pitfalls of the different fracture types are more useful. Among these are the optimal entry point for nailing and the integrity and the handling of greater trochanter fragments to avoid abductor insufficiency. Special attention is given to the rotational instability of the head-and-neck fragment and to how this is correctly treated by anti-rotation devices. - In addition, some cases show technical suggestions like the use of cerclage and the trochanteric buttress plate. - Finally, a plea is made for the technically demanding use of blade plates for rare special cases. 9

10 REFERENCES: 1. BABST R, RENNER N, BIEDERMANN M, ROSSO R, HEBERER M, HARDER F, REGAZZONI P CLINICAL RESULTS USING THE TROCHANTER STABILIZING PLATE (TSP): THE MODULAR EXTENSION OF THE DYNAMIC HIP SCREW (DHS) FOR INTERNAL FIXATION OF SELECTED UNSTABLE INTERTROCHANTERIC FRACTURES J ORTHOP TRAUMA, 12: 392-9, BHANDARI M, SCHEMITSCH E, JÖNSSON A, ZLOWODZKI M, HAIDUKEWYCH GJ. GAMMA NAILS REVISITED: GAMMA NAILS VERSUS COMPRESSION HIP SCREWS IN THE MANAGEMENT OF INTERTROCHANTERIC FRACTURES OF THE HIP: A META-ANALYSIS. J ORTHOP TRAUMA; 23:460-4, GARDNER MJ, ROBERTSON WJ, BORAIAH S, BARKER JU, LORICH DG: ANATOMY OF THE GREATER TROCHANTERIC BALD SPOT : A POTENTIAL PORTAL FOR ABDUCTOR SPARING FEMORAL NAILING? CLIN ORTHOP RELAT RES: 466, , CASES FROM THE ICUC APP DATABASE, THE INDIVIDUAL CASE IDENTIFICATION IS LISTED IN THE TEXT. 5. PARKER MJ, HANDOLL HH. GAMMA AND OTHER CEPHALO-CONDYLIC INTRAMEDULLARY NAILS VERSUS EXTRAMEDULLARY IMPLANTS FOR EXTRACAPSULAR HIP FRACTURES IN ADULTS. COCHRANE DATABASE SYST REV PERREN SM., FERNANDEZ A., REGAZZONI P FRACTURE FIXATION USING CERCLAGES, RESEARCH APPLIED TO SURGERY ACTA CHIRURGIAE ORTHOPAEDICAE ET TRAUMATOLOGIE CECHOSLOVACA, QUEALLY JM, HARRIS E, HANDOLL HH, PARKER MJ INTRAMEDULLARY NAILS FOR EXTRACAPSULAR HIP FRACTURES IN ADULTS COCHRANE DATABASE SYST REV 2014 SEPT 12 (9) 8. ROBERTS KC, BROX WT, JEVSEVAR DS MANAGEMENT OF HIP FRACTURES IN THE ELDERLY J AM ACAD ORTHOP SURG. 2015;23 : WENDT K, HEIM D, JOSTEN C, KDOLSKY R, OESTERN HJ, PALM H, SINTENIE JB, KOMADINA R, COPUROGLU C. RECOMMENDATIONS ON HIP FRACTURES EUR J TRAUMA EMERG SURG 42, ,