76 F: Plays tennis, lives independently, told she has weak bone

Transcription

1 Femoral Neck Fractures In the ELDERLY What to do, when and why Frank Liporace, MD Chairman & VP, Dept of Orthopaedics Chief of Trauma & Adult Reconstruction Jersey City Medical Center / RWJ Barnabas Health 76 F: Plays tennis, lives independently, told she has weak bone ZERO Displacement on the Cross-Table Lateral How would you classify this injury? 1- Subcapital FNF 2- Transcervical FNF 1

2 How would you classify this injury? 1- Non-Displaced & Impacted? 2- Displaced & Impacted? How would you treat this injury? 1-3 partially threaded cannulated screws 2-3 screws: 2 partial threads / 1 full threads 3- Sliding Hip Screw +/- Antirotation screw 4- Arthroplasty Risk Factors Age Only 2-3% of hip fractures occur in pts < 50 Epidemiology Incidence doubles each decade after 50 2

3 Hip Fractures - USA 1:7 women will have a hip fracture Men 1:17 risk 70% of survivors decreased function* 40-50% require walking aid* Younger elderly Offset Acetabular wear Mortality one year after a hip fracture 24-30% Source: US Surgeon General s Report on Osteoporosis, 2004 Magaziner et al Osseous Neck shaft angle 130+/- 7 deg Anteversion 10+/-7 degrees Minimal periosteum Covered w/ synovium Neck lies anterior to mid axis of proximal femur Consider High-Offset Implants Or Reduced Valgus Angle Necks with Elderly MUST PRE-OPERATIVELY TEMPLATE!!! Classification Garden [1961] I Valgus impacted or incomplete II Complete Non-displaced III Complete Partial displacement IV Complete Full displacement ** Portends risk of AVN and Nonunion Non-Displaced I Displaced II III IV 3

4 Classification Garden [1961] I Valgus impacted or incomplete II Complete Non-displaced III Complete Partial displacement IV Complete Full displacement ** Portends risk of AVN and Nonunion Non-Displaced FIX - CRPP I III Displaced HHA vs THA II IV If Displaced What is elderly? Not all elderly created equal ORIF, Unipolar, Bipolar, THA Lu Yao et al 1994 Displaced fractures: avg age 77 Nonunion 33% Secondary surgery >30% w/ ORIF 6-18% HHA If Displaced What is elderly? Not all elderly created equal ORIF, Unipolar, Bipolar, THA Lu Yao et al 1994 Displaced fractures: avg age 77 Nonunion 33% Secondary surgery >30% w/ ORIF 6-18% HHA 4

5 Davison 2001 Blomfeldt 2005 Rogmark 2002 Displaced Fx Failures - Secondary Surgeries ORIF 30% <3% 42% 4% 43% 6% Arthroplasty How would you judge the fracture position? 1- Acceptable? 2- Not Acceptable? Femoral Neck Fxs: Keys to a Good Repair Reduction Criteria AP 1-2 mm displacement Garden alignment index Slide courtesy H.C. Sagi MD 5

6 Femoral Neck Fxs: Keys to a Good Repair Reduction Criteria Lateral 1-2 mm displacement >170 +/-10 anatomic version Slide courtesy H.C. Sagi MD How would you judge the hardware choice & position? 1- Acceptable? 2- Not Acceptable? Significant INCREASE A-P Stiffness 6

7 CLINICAL STUDY: -Increased rigidity WORSE for Non-Displaced -Increased rigidity NO DIFFERENCE for Displaced Significant INCREASE Construct Stiffness, BUT Best Positioning for Stability 7

8 Screw Fixation Peripheral Screw Placement Within 3mm of calcar and posterior cortex (Lundquist et al, Acta Orthop Scand) Avoid Central screw placement Avoid P-S blood supply Not all Valgus Impacted are created equal Now what? 1- Leave alone / limited weight bearing 2- Revise fixation 3- Pauwel s Osteotomy with revised fixation 4- Arthroplasty 8

9 Could we have augmented screw fixation??? Surgeons Strip Screws 50% of Time in Cancellous Bone Higher AVN Rate Norian CaPO4 vs CONTROL??? 9

10 Extrusion Intrusion SOM 1 SOM 2 Slide Courtesy T. Russell, MD N-Force Axial Pullout Test No BSM vs. With B-BSM Bone Substitute Material Mean 3.5X Increase for Augmentation These graphs are representative of the data(n=5; MarTest Job ) N-Force No Bone Substitute Material 515+/-78.7 N Slide Courtesy T. Russell, MD Bench testing is not necessarily indicative of clinical performance. N-Force Plus Bone Substitute Material Augment /-148 N The ship has sailed, now we must make decisions relative to REPLACEMENT 10

11 Cemented vs Non-Cemented Cemented vs Non-cemented Cement Better acute fixation Results? Sudden Death? Gingras 1980, Sohne-Holm 1982, Emery 1991 Less pain, increased walking ability, similar complications w/ cementing Cemented vs Non-cemented Parvizi ,488 ( ) 22 intra-op deaths (0.06%) 0 intra-op deaths w/ noncemented Christie 1995 Bone Cement Implantation System Medullary lavage prior to cementation Decreased embolic phenomena and CV changes 11

12 Cemented vs Non-cemented Many early studies eval d Austin Moore, Thompson No analysis individually of Modern, Modular: M-L Taper Metaphyseal Fill Diaphyseal Fit Hemiarthroplasty vs THA Who does THA? Who has available THA surgeon? Over 65 years old w/ displaced FNF? Ambulation status: 1) COMMUNITY 2) Community w/ AD 3) Household 4) Household w/ AD Health status 12

13 THA vs HHA THA w/ less pain than HHA Dorr 1986 Skinner 1989 Gebhard 1992 Squires 1999 Lower revision rate w/ THA Skinner 1989 Gebhard 1992 Squires 1999 No difference in M & M Acetabular Wear Iorio 2001 Costs THA vs HHA Total costs (2yr) including complicataions, mortality, re-op, between: Unipolar $21,597 Bipolar $22,043 THA (hybrid) $21,066 THA (cemented) $20,670 13

14 12 RCTs Patients Lower Reoperation No Difference in Mortality Better Hip Function 1 year & 3-4 years NO DIFFERENCE: Infection Rate General Complication Articulation??? 14

15 Dislocation w/ THA for FNF n # early dislocation # late dislocation Coates Cartlidge Taine Sim Dorr Delamarter Pun Greenough Gebhard Lee TOTAL (10.2%) 17 (2.3%) Constrained Liner - Alternative Constrained Liner - Alternative 15

16 Constrained Liners - JP Constrained Liners - JP Dual Mobility Time proven in Europe Increased Stability with Jump Distance 2 articulations Low wear Volumetric analysis 2 sites of potential wear Can t be closed reduced if dislocate Dislocation usually intraprosthetic 16

17 Dual Mobility Primary THA patients 2% dislocations All dislocations were long neck All dislocations were femoral head from insert Dual Mobility 17

18 Dual Mobility Dual Mobility So, what to do??? Cement? Press-fit? HHA? THA? Standard Head? DM / constrained? 18

19 Not all Valgus Impacted are created equal Monday Morning Quarterback DISPLACEMENT 19

20 VALGUS ANGLE SHORTENED OFF- SET Take Home for DISPLACED FNF CRPP (SHORT-THREADED) for NON- DISPLACED or if patient is going to die with anything more and this is for pain relief / mobilization THA if community ambulator w/o assistive device and >65 y.o. HHA (Bipolar b/c same $ at my hospital) Try Non-cemented w/ M-L taper stem If fit is questionable - cement 20

21 Take Home for DISPLACED FNF CRPP for NON-DISPLACED or if patient is going to die with anything more and this is for pain relief / mobilization THA if community ambulator w/o assistive device and >65 y.o. HHA (Bipolar same $ at most hospitals) Try Non-cemented w/ M-L taper stem If fit is questionable - cement What makes sense to me What makes sense to me 21

22 ` THANK YOU 22