Introduction. Femoral neck fracture in the elderly

Transcription

1 Fll Fellow: 姜智偉

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3 Introduction Femoral neck fracture in the elderly % mortality tlit rate in the first year Highest in the first 6 months, then gradually reduced Affect mortality: Age, gender, comitant medical or psychiatric condition, level of preinjury functioning or ESRD Improved fixation and early mobilization in recent years perioperative death 5%, first year 25% Rockwood and Greens : Fracture in Adults 6 th edition

4 Femur neck fracture (OKU9) Classification Garden Classification Pauwel classification

5 Garden Classification

6 Pauwel classification

7 Management Treatment method should based on Age Displacement Bone quality Comobidity Mobility status before injury Hip pathology before injury Economic issue

8 Nondisplaced Fractures (OKU9) Surgical benefit Pi Pain control Prevent further displacement Nonsurgical treatment is reserved for severe medical comobidity Pre op traction has not been shown improve pain control but is associated with sciatic neuropathy ( about 0.7%)

9 Nondisplaced Fractures (OKU9) Treatment: Three cannulated ltd screws Inverted triangle Above lesser trochanter Screws threads should not pass fracture site Nonunion :5%. Osteonecrosis:10% Ambulate within 2 weeks living at home 1 year after operation

10 Displaced fracture in Young Adults(OKU9) Surgical treatment as soon as possible Anatomic reduction or mild valgus deformity (<15 degrees) is acceptable. Open reduction for irreducible fracture Fixed angle device High verticality Severe comminution Lateral basicervical fracture Capsulotomy:??? Nonunion rate: 10 30% and Osteonecrosis: 15 33%.

11 Displaced fracture in Elderly patients (OKU9) High failure rate of internal fixation Arthroplasty has good functional outcome Hemiarthroplasty: Unipolar Hrmiarthroplasty: Bipolar Total hip arthroplasty

12 Displaced fracture in Elderly patients (OKU9) Hemiarthroplasty had low dislocation rate Stroke patients t Parkinson s disease Advanced d dementia Total hip arhroplasty Pre exiting acetabular disease Rheumatic arthritis

13 Cementless vs cemented stem Cemented stem Less thigh h pain Relative good function outcome Concern of PMMA toxicity i Cementless stem Thigh pain Intra operativer femur fracture

14 PMMA toxicity Systemic and Circulatory effect Decrease blood pressure with peripheral vasodilatation ti Decrease arterial oxygen tension Cement block pulmonary circulation i Intra operative echocardiography showed echogenic material during cement insertion Cement may decrease myocadial function Hypersensitivity Biomechanics and biomaterials in orthopedics Dominique G. Poitout Daniel Nazon et al. Critic CareClin

15 Cement extravasation result in stroke F A Maden et al. AJNR J

16 Cement related complication Risk factor Elder patient t Associated malignancy Cardiac or pulmonary disease Prevention Maintain adequate volume Keep high arterial oxygenation Vasopressor to keep normal blood pressure High volume and pulsatile lavage femoral canal Daniel Nazon et al. Critic CareClin

17 Evident Based Medicine Cemented vs uncemented hemiarthroplasty Unipolar vs Bipolar hemiarthroplasty h Total hip arthroplasty vs hemiarthroplasty

18 Cemented hemiarthroplasty versus uncemented hemiarthroplasty Branfoot 2000: Cemented Thompson prosthesis versus an uncemented Thompson prosthesis (91 participants). Emery 1991: Cemented bipolar Thompson prosthesis versus an uncemented bipolar Moore prosthesis (53 participants). Harper 1994: Cemented Thompson prosthesis versus an uncemented Thompson prosthesis (137 participants).

19 Cemented hemiarthroplasty versus uncemented hemiarthroplasty Parker 2009: Cemented Thompson prosthesis versus an uncemented Austin Moore prosthesis (400 participants). Santini 2005: Cemented bipolar prosthesis versus an uncemented bipolar prosthesis (106 participants). Sonne Holm 1982: Cemented Austin Moore prosthesis versus an uncemented Austin Moore prosthesis (112 participants).

20 Moore hemiarthroplasty Austin Moore hemiarthroplasty Thompson Moore hemiarthroplasty

21 Law issue If cemented stem is better than cementless stem Poor evidence : Additional procedure result in patient t complication. Good evidence: Protect our medical practice more or Good evidence: Protect our medical practice more or less

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40 Conclusion Good evidence for Cemented group has less post operative ti pain Cemented group has longer operation time Cemented group has better post operative mobility Cemented group has less intra operative femur fracture l d l l d l As to mortality, medical complications, dislocation or deep sepsis, there is no statistical difference.

41 Future Pain post operative mobility Improve post operative ti pain management Osteoporosis and stem design Newer stem design to increase bone prosthesis affinity Post operative anti osteoporosis medication Bioabsorpable cement with less toxicity Vertebroplasty, cemented DHS, shoulder hemiarthroplasty. Need further EBM to prove cement safety.

42 Thank you