Angular Malalignment in Subtrochanteric and Proximal Shaft Femur Fractures after Intramedullary Nailing using SIGN Nails

Transcription

1 Angular Malalignment in Subtrochanteric and Proximal Shaft Femur Fractures after Intramedullary Nailing using SIGN Nails Rolando Junior L. Torres, MD Jeremiah R. Morales, MD, FPOA

2 Subtrochanteric Femur fracture 5 cm from below the level of the lesser trochanter to a level 5cm distal to it

3 Proximal Shaft Femur fracture femoral diaphysis from 5cm distal to the lesser trochanter up to 5cm proximal to the adductor tubercle diaphyseal region is then divided into 3 equal parts first 3 rd or proximal division is known as the proximal shaft

4 Angular malalignment more than 5 degrees of angular deformity in the sagittal or coronal planes Varus Valgus Procurvatum Recurvatum Ricci, WM et al. Angular Malalignment After Intramedullary Nailing of Femoral Shaft Fractures. Journal of Orthopaedic Trauma Vol. 15, No. 2, pp

5 STABLE UNSTABLE

6 Subtrochanteric & Proximal Femoral Shaft Fractures Functionally distinct from intertrochanteric and femoral shaft fractures Technically challenging to manage Has distinct complications

7 Technically challenging Gluteal and short external rotator muscles abduction & external rotation of the hip Iliopsoas - flexion of the proximal fragment Adductor muscles shorten & medialize the distal femur

8 Subtrochanteric & Proximal Femoral Shaft Fractures VARUS malalignment Most noted complication >5 degrees angulation in coronal/sagittal planes Ostrum, R.F. et A Critical Analysis of the Eccentric Starting Point for Trochanteric Intramedullary Femoral Nailing. Journal of Orthopedic Trauma. November/December 2005 Ricci, WM et al. Angular Malalignment After Intramedullary Nailing of Femoral Shaft Fractures. Journal of Orthopaedic Trauma Vol. 15, No. 2, pp

9 incidence of malalignment was 9 % for the entire group of patients (proximal, middle and distal femur fractures) 30 percent when the fracture was of the proximal portion of the femur

10 Clinical Consequences of Varus Malalignment 1. Decrease in HIP ABDUCTOR MUSCLE EFFICIENCY pain limp Weakness Papp, S., Gofton, W., Liew, A.S.L. (2012). Subtrochanteric Fractures. In Bhandari, M. Evidence-Based Orthopedics (pp ). West Sussex, UK: Wiley-Blackwell

11 Clinical Consequences of Varus Malalignment 2. FIXATION FAILURE 26% and NON- UNION Due to increase in effective lever arm on the fixation Increase amount of force around the hip joint

12 Treatment Recommendation Fracture patterns distal to the lesser trochanter: Antegrade, Reamed, Statically locked, Intramedullary nail Lee, M.A. et al Fractures of the Proximal Femur. Schimdt, A.H. and Teague, D.C., editors. Orthopedic Knowledge Update 4 th ed: Trauma. Illinois: American Academy of Orthopedic Surgeons p Nork, SE, et al., Subtrochanteric Fractures of the Femur. Browner, BD., Levine, AM., Jupiter, JB., Trafton, PG., Krettek, C. Editors. Skeletal Trauma 4 th ed. Philadelphia, PA: Elsevier Vol. 2 Ch. 51 p

13 Static Interlocking Intramedullary Nails Price Range: $ 300 3,500 (P 13,500 P157,500)

14 Surgical Implant Generation Network (SIGN) Nails Intramedullary implants for: Femur Tibia Humerus Solid nail No arc of radius 9 degrees proximal bend

15 Through 14 years of using SIGN SURGICAL TREATMENT PROTOCOL Open Reduction Secure Reduction prior to reaming and nail insertion Using appropriate nail size Trochanteric entry point SIGN Nails (CENTER OF EXCELLENCE) Piriformis Fossa Traditional Entry Point 2-3 mm medial to tip 2-3 mm lateral to tip Greater Trochanter SIGN Entry Point

16 Through 12 years of using SIGN Nails

17 Research Questions What is the incidence of angular malalignment after intramedullary nailing of subtrochanteric and proximal shaft femoral fractures? Which fracture site will result to high incidence of angular malalignment? Subtrochanteric or Proximal Shaft?

18 Research Questions To what degree of fracture comminution will result to high incidence of angular malalignment? What are the associated complications of intramedullary nailing in subtrochanteric and proximal shaft femoral fractures?

19 Significance of the Study investigating the incidence of angular malalignment in these fractures: would give a statistics of the cases involved provide inputs for review of our current SIGN surgical treatment protocol lead to a line of researches in refining surgical techniques and investigating clinical outcomes for these complicated and challenging ur fractures

20 Objective of the Study To determine the incidence of angular malalignment in subtrochanteric and proximal shaft femoral fractures treated with SIGN intramedullary nails

21 Specific objectives 1. Incidence of angular malalignment in: Subtrochanteric femoral fractures Proximal shaft femoral fractures 2. Which among the proximal femoral fracture sites has the highest risk of angular malalignment. 3. Risk of angular malalignment according to the degree of fracture comminution. 4. Associated complications in intramedullary fixation of subtrochanteric and proximal shaft femoral fractures.

22 METHODOLOGY Research Design retrospective cohort study design Setting chart and radiographs reviews of patients admitted between January to December 31, 2012

23 Participants (Inclusion & Exclusion Criteria) 73 patients were included in the study INCLUSION EXCLUSION Subtrochanteric and Proximal Femur Shaft fractures treated with SIGN Nails Patients treated with plates and intramedullary nails other than SIGN nails pathologic fractures subtrochanteric fractures with extension to: greater trochanter lesser trochanter piriformis fossa

24 Sampling Procedures Sample size - computed using the software Samp size

25 Data Gathering Independent Variables location of fracture degree of comminution according to Winquist classification Associated complications Dependent Variable ANGULAR MALALIGNMENT Varus Valgus Procurvatum Recurvatum

26 Data Handling and Analysis 1. Descriptive Analysis utilized frequency for qualitative variables 2. Statistical Analysis Chi-square analysis Epi Info version level of significance is set at 0.05

27 Results & Discussion

28 Table 1. Characteristics of Patients with Subtrochanteric and Proximal Femoral shaft Fractures from January 1, 2003 to Dec 31, 2012 Fracture Location Characteristics Subtrochanter (n=50) Proximal Shaft Femur (n=23) p-value Sex freq (%) Male 44 (88) 21 (91) Female 6 (12) 2 (9) Age ( x ± sd ) 33 ± ± Mechanism of Injury freq (%) Vehicular Crash 23 (46) 16 (69) Fall 13 (25) 3 (14) Gunshot Injury 9 (18) 1 (4) Others 5 (10) 3 (14) Comminution freq (%) Winquist 0 16 (32) 13 (56) Winquist I 11 (22) 3 (13) Winquist II 6 (12) 3 (13) 0.41 Winquist III 5 (10) 2 (9) Winquist IV 12 (24) 2 (9)

29 attributed to the following facts applicable in our setting males lead a more active life than females males are more inclined to risk taking behavior most males are motorcycle drivers by occupation most males have motorcycles as means of transportation Morales, J., The Profiles of Patients Involved in Motorcycle Accidents Admitted at the Department of Orthopedics, Davao Medical Center from January 2004 to December Retrieved from Department of Orthopedics, Southern Philippines Medical Center Archive

30 Table 1. Characteristics of Patients with Subtrochanteric and Proximal Femoral shaft Fractures from January 1, 2003 to Dec 31, 2012 Fracture Location Characteristics Subtrochanter (n=50) Proximal Shaft Femur (n=23) p-value Sex freq (%) Male 44 (88) 21 (91) Female 6 (12) 2 (9) Age ( x ± sd ) 33 ± ± Mechanism of Injury freq (%) Vehicular Crash 23 (46) 16 (69) Fall 13 (25) 3 (14) Gunshot Injury 9 (18) 1 (4) Others 5 (10) 3 (14) Comminution freq (%) Winquist 0 16 (32) 13 (56) Winquist I 11 (22) 3 (13) Winquist II 6 (12) 3 (13) 0.41 Winquist III 5 (10) 2 (9) Winquist IV 12 (24) 2 (9)

31 Table 2. Comparison of the rate of angular malalignment between subtrochanteric and proximal shaft femoral fractures OUTCOME Subtrochanteric Proximal Shaft p-value Femur (n-50) Femur (n=23) Angular 22 (46) 2 (9) Malalignment freq (%) Varus freq (%) 12 (24) 1 (4) Valgus freq (%) 2 (4) Procurvatum freq (%) 5 (10) Recurvatum freq (%) 2 (4) 1 (4) Varus & Procurvatum freq (%) 1 (2)

32 CURRENT STUDY RELATED LITERATURES 46% incidence of angular malalignment in subtrochanter VARUS angulation most common deformity incidence of malalignment was 9 % for the entire group of patients (proximal, middle and distal femur fractures) 30 percent when the fracture was of the proximal third of the femoral shaft Ricci et al. JOT % post operative angular malalignment in subtrochanteric fractures Nork, SE, Skeletal Trauma 4 th ed 2009 Papp, S et al. Evidence-Based Orthopedics 2012

33 Factors leading to malalignment in subtrochanteric fractures 1. Deforming muscular forces Makes intra-op reduction difficult good reduction key to avoiding malreduction greatly achieved through open approach 2. More voluminous canal in proximal femur than in diaphysis Lessens contact of bone and IM nail Opposed by Ricci et al JOT 2001 NO CORRELATION between angular deformity and nail diameter-canal contact

34 Table 3. Comparison of the rate of angular malalignment by degree of comminution Stable Fractures (Winquist 0-II) Unstable Fractures (Winqust III-IV) p-value n=52 n=21 Angular Malalignment freq (%) 16 (30) 8 (38) NOT SIGNIFICANT

35 Table 3. Comparison of the rate of angular malalignment by degree of comminution Stable Fractures (Winquist 0-II) Unstable Fractures (Winqust III-IV) p-value n=52 n=21 Angular Malalignment types Varus 6 (12) 7 (33) Valgus 2 (4) Procurvatum 5 (10) Recurvatum 2 (4) 1 (5) Varus & Procurvatum 1 (2)

36 Further analysis revealed Odds Ratio of having varus malalignment whether the fracture pattern is STABLE or UNSTABLE >1 ( )

37 Similar result Ricci et al Journal of Trauma 2001 High incidence of malalignment in proximal femur fractures regardless of the degree of comminution Other factors must be sought as a possible cause of malalignment Entry point issue???

38 Ostrum, R.F., Marcantonio, A., DO, Marburger,R. A Critical Analysis of the Eccentric Starting Point for Trochanteric Intramedullary Femoral Nailing. Journal of Orthopedic Trauma. November/December Vol 19., No. 10 Adequate selection of nail entry point Has significant effect on fracture alignment aside from deforming forces Noted angular deformity in IM nails with more proximal bend Piriformis Fossa Traditional Entry Point 2-3 mm medial to tip Significant 6-8 degrees of malalignment when Greater trochanteric tip entry point used 2-3 mm lateral to tip Greater Trochanter SIGN Entry Point

39 Table 4. Comparison between associated complications in intramedullary fixation of subtrochanteric and proximal shaft femoral fractures Complications freq (%) Subtrochanteric Proximal Shaft p-value Femur (n=50) Femur (n=23) Iatrogenic Medial cortex comminution Iatrogenic Lateral cortex comminution Femoral Neck Fractures Gapping of lateral cortex Others 4 (8) 0 (0) (4) (6)

40 Greater Trochanteric Entry Point Too lateral Reaming becomes eccentric Nail insertion goes toward the medial cortex causing comminution Streubel, P.N., Wong, A.H.W., Ricci, W.M., Garner, M.J. Is There A Standard Trochanteric Entry Site for Nailing of Subtrochanteric Femur Fractures? Journal of Orthopedic Trauma. April Vol. 25, No. 4

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43 CONCLUSIONS

44 CONCLUSIONS 1. Incidence of angular malalignment: 46% in subtrochanteric femoral fractures 9% in proximal femoral shaft fractures 2. Varus deformity: 24% incidence rate Subtrochanteric location is a significant factor for angular malalignment

45 CONCLUSIONS 3. The relationship between the degree of fracture comminution and angular malalignment is not significant. However, further analysis showed that in unstable fractures there is a risk for varus malalignment with and odds ratio of >1. 4. Subtrochanteric location also posed a risk for iatrogenic medial comminution

46 SIGN NAIL CONFIGURATION and ENTRY POINT may impose significant risk for angular malalignment especially for subtrochanteric fractures

47 THANK YOU!