Evaluation and Treatment of High Energy Proximal Femur Fractures OVERVIEW 6/23/2014. Introduction of Speakers - Objectives (2 minutes)

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1 6/23/2014 Evaluation and Treatment of High Energy Proximal Femur Fractures OVERVIEW Introduction of Speakers - Objectives (2 minutes) Injury Patterns, Evaluation - Patient Considerations Mike Gardner -- (10 minutes) Operative Fixation: Nail - Dave Barei (10 minutes) Operative Fixation: Plate - Tim Achor (10 minutes) Problems and Complications - David Asprinio (10 minutes) Discussion/Cases/Q+A (20 minutes) 1

2 Michael J. Gardner, MD Washington University School of Medicine St. Louis, MO High E Proximal Femur Fx 1. Femoral neck 2. Pertrochanteric 3. Subtrochanteric Femoral neck fractures 1) Intracapsular

3 Femoral neck fractures 1) Intracapsular Implications: Synovial fluid bathed Endosteal healing Femoral neck fractures 2) Blood supply Femoral neck fractures 2) Blood supply Implications: Tenuous Frequently disrupted

4 Femoral neck fractures 2) Blood supply Disruption depends on : Displacement Superior exit point Femoral neck fractures 2) Blood supply Disruption depends on : Displacement Superior exit point Femoral neck fractures 3) Age Implications: Physiologic Activity level arthroplasty?

5 Femoral neck fractures 4) Occult in femoral shaft fractures Femoral neck fractures 5) Radiography Hip frequently externally rotated Difficult to visualize fracture CT SCAN Femoral neck fractures Pauwels Classification [1935] Verticality Shear forces 0% non-union 13% AVN 8% non-union 30% AVN 12% non-union 35% AVN

6 Femoral neck fractures 6) Surgical timing Priortize REDUCTION and quality of surgery rather than TIME TO OR Pertrochanteric fx Pertrochanteric fx 1) Simple fx do not behave like geriatric fx Implications: Plan for open reduction Avoid fracture table

7 Pertrochanteric fx 1) Simple fx do not behave like geriatric fx Pertrochanteric fx 2) Radiography Define: Fracture lines Deformity FN extension Subtroch extension Stress views Pertrochanteric fx 2) Radiography Define: Fracture lines Deformity FN extension Subtroch extension Stress views CT SCAN if question

8 Pertrochanteric fx 2) Radiography Pertrochanteric fx 3) Search for subtrochanteric extensions that are able to be clamped Pertrochanteric fx 3) Search for subtrochanteric extensions that are able to be clamped

9 Subtrochanteric fx vs vs Wide Spectrum Subtrochanteric fx Classic deforming forces: Proximal segment Flexion Abduction ER Distal segment Adduction Shortening Subtrochanteric fx 1) Radiography Quality AP and lateral to understand fracture and deformity

10 Subtrochanteric fx 1) Radiography Quality AP and lateral to understand fracture and deformity Summary Proximal femur fractures are highly variable Different anatomic regions have different treatment implications Accurate understanding of fracture pattern is paramount Thank You

11 6/23/2014 Operative Fixation: Nail Evaluation and Treatment of High Energy Proximal Femur Fractures David P. Barei MD, FRCSC Associate Professor Harborview Medical Center / University of Washington Seattle, WA barei@uw.edu Disclosure Teaching Honoraria (AO) Synthes Consultant (implant design) Journal Reviewer JBJS-A, J Orthop Trauma, CORR AO Fellowship Committee Institutional-UW Ortho-Research AO Spine North America AO-Stiftung-ASIF Foundation Bank of America Foundation The Center, Orthopaedics and Neurological Surgeons Fidelity Investments Helena Orthopaedics Clinic Illinois Orthopaedics & Hand Center Inland Orthopaedics of Spokane JMS Hand Associates Northwest Biomet, Inc. Pacific Rim Orthopaedics Proliance Surgeons, Inc. Proliance Orthopeadics & Sports Medicine The Seattle Foundation Seattle Christian Foundation Silicon Valley Community Foundation Simonian Sports Medicine Clinic SKS Plastic Surgery Spectrum Research Synthes U.S.A. Synthes Spine Co. Washington Research Foundation Washington State Orthopaedics Association Webber Lawn & Yard Care National Institutes of Health (NIH) National Science Foundation (NSF) Veterans Affairs Rehabilitation Research and Development Service Orthopaedic Research and Education Foundation (OREF) A.O. North America Amgen, Inc. Bayer AG BioAxone Therapeutique, Inc. CeraPedics, LLC Christopher Reeve Paralysis Foundation Depuy (Johnson & Johnson, Inc. ) Foundation for Orthopedic Trauma Integra Lifesciences Corporation National Science Foundation Ostex International, Inc. Orthopaedic Trauma Association Paradigm Spine Smith & Nephew Synthes Spine Co. The Boeing Company US Army Research Office US Department of Education 1

12 6/23/2014 Definition Inferior border of lesser 5 centimeters 8 centimeters Proximal 1/3 of femur What are the problems/difficulties with subtrochanteric fractures? 1. High mechanical stresses 2. Powerful muscular deforming forces on the proximal segment 3. Complicated patterns 4. Relative avascularity High Mechanical Stresses Maximal Compressive Forces Medially (2-8 cm below lesser) (1200 lb/in 2 ) High Tensile Forces Laterally 2

13 6/23/2014 Deforming Forces Flexion Abduction External rotation Complex Fracture Patterns Infrequently confined to the subtrochanteric region! Proximal extensions into the intertrochanteric region Implant choices Plates Lateral fixed angle implant Angled blade plate Dynamic condylar screw Lateral locked fixed angle implant (PFLP) Sliding hip screw (DHS) Nails Piriformis start antegrade nail Cephalomedullary nail Trochanteric versus piriformis starting point Head fixation (2 small versus 1 large fixation device) (blade versus screws into head) 3

14 6/23/2014 Implant choices Plates Lateral fixed angle implant Angled blade plate Dynamic condylar screw Lateral locked fixed angle implant (PFLP) Sliding hip screw (DHS) Nails Piriformis start antegrade nail Cephalomedullary nail Trochanteric versus piriformis starting point Head fixation (2 small versus 1 large fixation device) (blade versus screws into head) Why Choose A Nail? Biomechanics 4

15 6/23/2014 Biomechanics of Fixation Tencer et al, JOR, 1984 Plates (DHS, ABP) and Nails (Enders, Zickel, 3 locked nails) Cadaveric specimens with and without bone contact Plates stronger in torsion (50% vs 5%) Both demonstrated bending ~80% of intact Load to failure: Nails ( % body wt) Plates ( % body wt) Pugh et al, JOT, st vs 2nd generation nails Stable & Unstable Increased stiffness in torsion & compression in 2nd generation nails Soft Tissue Friendly What are the problems/difficulties with subtrochanteric fractures? 1. High mechanical stresses 2. Powerful muscular deforming forces on the proximal segment 3. Complicated patterns 4. Relative avascularity Starting point errors with nailing FAILURE TO REDUCE PRIOR TO NAILING!!! 5

16 6/23/2014 Locked Antegrade Nail Allows indirect reduction techniques (Medullary Splint) Good biomechanical properties Familiar technique Accurate Start Point Correct Deformity Before Nailing!!! Accurate Entrance Trajectory Correct Flexion Correct Abduction Correct Rotation Reduction Proximal reduction (opposite of femoral shaft fractures) Time limit for closed maneuvers! Supine vs. Lateral position Tools F-tool Spike pusher Schanz pin(s) Large clamp Intramedullary reduction Open reduction 6

17 6/23/ yo female fell while rock climbing Accurate start point, accurate entrance trajectory, percutaneous and accurate reduction during reaming and nail insertion 7

18 6/23/2014 Open reduction, limited dissection, pointed reduction clamps and provisional large diametered K-wires Scolaro, Injury 2013 Open reduction, limited dissection, pointed reduction clamps and provisional large diametered K-wires 3 months postop Scolaro, Injury

19 6/23/2014 Clamp Assisted Reduction of High Subtrochanteric Fractures of the Femur. Afsari et al, JBJS, of 44 fractures united Percutaneous technique Excellent reduction Specific fracture patterns Successful technique Open Reduction and IM Stabilisation of Subtrochanteric Femur Fractures. Beingessner et al, Injury, patients treated with open reduction and IM nailing All fractures united Open reduction technique with limited dissection 98% united within 5 of anatomic in the coronal and sagittal planes No wound complications or infections However If you re going to open a subtrochanteric fracture Do it nicely!!! 9

20 6/23/2014 Cephalomedullary Nails. Piriformis Recon Trochanteric Recon Trochanteric Hip Screw Cephalomedullary Nails. Piriformis Recon Personally preferred for lower subtrochanteric fractures where there remains some diaphyseal shaped canal on the proximal segment Helps with reduction Anatomic axis of the femur More commonly used in younger patients with higher quality bone Requires a slightly more anterior start point than typical piriformis nailing Piriformis Centromedullary Nail Start Point 10

21 6/23/2014 Piriformis Cephalomedullary Nail Start Point 5 mm Reconstruction = Cephalomedullary = Second Generation Nail Piriformis Cephalomedullary Nail Start Point Reconstruction = Cephalomedullary = Second Generation Nail Cephalomedullary Nails. Trochanteric Recon Personally preferred for the higher subtrochanteric femur fracture ± intertrochanteric involvement Allows proximal locking to be more collinear with midcoronal plane of the femoral head/neck Can use the nail to aid in rotational reduction (built-in nail version ) Requires strict attention to accurate start point to avoid varus malalignments 11

22 6/23/2014 Cephalomedullary Nails. Trochanteric Recon Recommendation The tip of the trochanter, or even slightly medial to the tip, should be the entry site of choice for antegrade trochanteric nailing of subtrochanteric fractures. The lateral starting point, even 2-3mm from the tip of the trochanter, is to be avoided Trochanteric Cephalomedullary Nail Start Point Piriformis Recon Trochanteric Recon Cephalomedullary Nails. Trochanteric Hip Screw Single screw cephalomedullary nails Typically demonstrate large proximal nail diameters Large single screw/blade proximal femoral head/neck interlock Consider these as geriatric fracture implants developed for unstable pertrochanteric fractures in that population Requires substantial bone removal in younger patients 12

23 6/23/2014 Trochanteric Hip Screw Trochanteric Hip Screw Nails versus Plates Systematic review of outcomes of extramedullary and intramedullary fixation Three Level I and Nine Level IV studies reviewed Grade B (fair) evidence shows Operative time reduced with IM fixation Fixation failure reduced with IM fixation Kuzyk et al. Intramedullary vs. extramedullary fixation for subtrochanteric fractures. (J Orthop Trauma 2009;23: ) 13

24 6/23/2014 Summary High force concentration region Notoriously difficult to treat Common deformities Flexion Abduction External Rotation Complex patterns with proximal extensions Trochanteric, piriformis, lesser, comminution Summary IM Nails are suitable devices mechanically, but require attention to detail Anticipate the predictable deformities Reduce BEFORE nailing (using multiple tools and approaches) Don t hesitate to open, but do it nicely Piriformis and trochanteric reconstruction nails are very effective but require accurate start points and entrance trajectories! Reserve medullary hip screw implants for physiologically older patients and fractures if possible Thank You HMC Trauma Faculty Barei, Beingessner, Bellabarba, Benirschke, Dunbar, Ferguson, Firoozabadi, Hanel, Hansen, Henley, Kleweno, Sangeorzan, Smith, Taitsman 14

25 6/18/2014 HIGH ENERGY HIP FRACTURES: PLATING TECHNIQUES Timothy S. Achor, MD UT Houston Memorial Hermann Hospital OBJECTIVES Discuss why high energy proximal femur fractures are different from geriatric hip fractures Discuss why plating these fractures is ideal Tips, tricks, pitfalls, recommendations NOT ALL HIP FRACTURES ARE CREATED EQUAL 1

26 6/18/2014 HIGH ENERGY HIP FRACTURES MVC, MCC, FALL FROM HEIGHT Flexed Abducted Externally rotated NAIL VS PLATE? Trend towards intramedullary nails for proximal femur fractures Advantages: Biomechanical advantage Percutaneous technique Decreased OR time Disadvantages Abductor mechanism Reaming Easy to introduce varus 2

27 6/18/2014 SURGERY REDUCTION IMPLANT SURGERY REDUCTION CLOSED OPEN IMPLANT PLATE NAIL 3

28 6/18/2014 REDUCTION? Almost always OPEN You already have the incision Why disrupt endosteal blood supply and ream a hole in proximal femur? TREATMENT OPTIONS: PLATE SLIDING HIP SCREW DYNAMIC CONDYLAR SCREW PROXIMAL FEMUR PLATE ANGLED BLADE PLATE SLIDING HIP SCREW Intertrochanteric fractures Subtrochanteric fractures* Basilar neck fractures *NOT reverse oblique FOR USE IN STABLE FRACTURES CONTROLLED COLLAPSE 4

29 6/18/2014 OPTIONS Barrel length CCD angle Plate length LONG 135 degree 2 4 hole Tip-Apex Distance (TAD) 5

30 6/18/2014 Dynamic Condylar Screw Transverse subtroch fractures Short oblique subtrochanteric fractures Long oblique subtrochanteric fractures 1. Roy Sanders and P.Regazzoni. Treatment of Subtrochanteric Femur Fractures Using the Dynamic Condylar Screw. Journal of Orthopaedic Trauma, vol. 3, no. 3, New York: Raven Press, DJ9235A 16 Proximal Femur Locking Plates Anatomic, precontoured plate Multiple fixed angled screws MIPO (theoretical?) Submuscular Locking/cortical screws on shaft + / - 6

31 6/18/2014 ANGLED BLADE PLATE Excellent historical track record Preferred implant for nonunions Technically challenging Relatively unforgiving 95 degrees must be righteous 7

32 6/18/2014 BLADE PLATE? Simple fracture patterns Patterns amenable to lag screws Patterns amenable to compression Patterns amenable to loading Extension into neck Extension into greater trochanter Lateral cortical read/apposition most important 8

33 6/18/2014 POST-OP PROTOCOL PROTECTED WEIGHT-BEARING X 8-12 WEEKS Monitor follow-up xrays closely May allow weight-bearing as early as 6 weeks Malreduction Varus Varus PITFALLS Varus Using a plate when a nail might have been better Load-BEARING vs load-sharing NOT TENSIONING THE PLATE!!! 9

34 6/18/2014 CASE 1 32 M s/p MVC Complaining of severe right hip pain +EtOH 10

35 6/18/ M s/p MVC 11

36 6/18/2014 Fracture table? Open or closed reduction? Nail vs Plate? 12

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39 6/18/2014 ARTICULATED TENSION DEVICE LOAD THE FRACTURE TENSION THE PLATE 15

40 6/18/ M s/p MCC 16

41 6/18/2014 TREATMENT OPTIONS? SAME OPTIONS? 17

42 6/18/2014 TREATMENT? 6 WEEK F/U 18

43 6/18/ M, ped struck 19

44 6/18/2014 TREATMENT OPTIONS? 20

45 6/18/ YEAR FOLLOW UP 22 M s/p MCC 21

46 6/18/ month follow-up 22

47 6/18/2014 IN CONCLUSION Not all proximal femur fractures are equal Age, Energy, Comminution, Personality DIFFICULT fractures to treat Treat each fracture individually with what works best in YOUR hands Consider the 95 degree angled blade plate WITH the articulated tension device for simple, loadable fracture patterns. THANK YOU 23

48 6/19/2014 Evaluation and Treatment of High Energy Proximal Femur Fractures Problems and Complications David E. Asprinio, M.D. 6/23/ MINUTES THESE ARE COMPLEX PROBLEMS NO UNIVERSAL SOLUTION OPTIONS Intramedullary fixation Blade plate fixation Proximal femur locking plates Compression hip screw 95 degree dynamic condylar screw External fixation Whatever Replacement is done arthroplasty needs to be done well Many Skeletal principles traction apply to prevention and treatment Avoiding problems and complications Evaluate the patient and radiographs Consider co-morbidities and other injuries Need a plan and a backup plan Need to be familiar with multiple modalities Know what can be done and know your limitations Reduction is critical Must achieve and maintain Intramedullary devices don t achieve reduction Fixed angle devices may achieve reduction however placement is critical Avoid unnecessary soft tissue dissection 1

49 6/19/2014 RS 1/24/07 INTROPERATIVE TRACTION RS 1/25/07 2

50 6/19/2014 VM 76 y/o male 3/9/12 GD 81 y/o male 4/29/14 3

51 6/19/2014 GD 4/30/14 4

52 6/19/2014 GD 6 weeks 5

53 6/19/2014 DA 26 y/o male 3/17/12 TRACTION IN OR Can t overstate value of femoral distractor and shanz pins as joysticks DA 3/17/2012 6

54 6/19/2014 DA 6 months JM 65 y/o male 7

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56 6/19/2014 When complications occur Evaluate the patient and radiographs Why did failure occur? Mechanical Reduction Choice of implant Placement of implant Biological Infection Osteoporosis Metabolic bone disease Patient non compliance Treating complications Address prior deficiencies in treatment Need plan and backup plan Need to be facile with multiple modalities Know what can be done and know your limitations MUST ACHIEVE REDUCTION CORRECT VARUS AND FLEXION ABNORMALITIES 9

57 6/19/2014 WL 51 Y/O MALE 10/ months 10/24/13 ROH, compression plating with restoration of alignment, allograft, stem cell autograft WL 6 months FWB without pain 10

58 6/19/2014 ES 88 y/o male 12/2013 ES 2/25/14 2months 11

59 6/19/2014 Summary It is better to avoid than treat complications Preoperative planning is critical Have multiple treatment options available Optimizing the mechanical and biological environment will increase the likelihood of successful treatment 12