Femoral Anatomy 11/27/2012. Geriatric Fractures: Complex Proximal Femoral Fractures

Transcription

1 Geriatric Fractures: Complex Proximal Femoral Fractures Clifford B. Jones, MD FACS Orthopaedic Associates of Michigan Michigan State University/CHM Butterworth Hospital, Spectrum Health Grand Rapids, MI Geriatric Fractures: Complex Proximal Femoral Fractures Clifford B Jones, MD FACS Disclosure Information The following relationships exist: Research: DOD, NIH, OTA Speaker s Bureau: AONA Ownership: Midtowne ASC, Partial Owner Femoral Anatomy 1

2 Neck Shaft Angle Danger! Soft Bone Beware of Fixation 1200 mm or 39 Inches Femoral Radius Of Curvature AAOS 2008 ICL 424 Femoral Neck Fractures 2

3 Minimally Displaced Femoral Neck Fx 10-15% AVN 10-15% Nonunion FWBAT Minimally Displaced Fx Fixation Cannulated Screws Compression Hip Screw Intramedullary Nail Locked Proximal Plate Displaced Femoral Neck Fx 30-40% AVN 30-40% Nonunion Replace Femoral Head FWBAT 3

4 Hemiarthroplasty Avoid Fracture & Subsidence Cementless Stem: State of the Art Arthroplasty Translation to Geriatric Fx: Fracture Limited WB Subsidence Pain Total Hip Arthroplasty LLD Dislocation Blood Loss 4

5 Basicervical/IT Hip Initial Post Op Severe Collapse & AVN 5

6 THA Femoral neck Fx Femoral Neck Fx, Garden I CR, Perc Screw Fixation Watch Screws Below LT Level (20% Fx Rate) 6

7 At 3 wks: In NH Fall Spiral ST Femur Below FN Fx Maintain FN Screws Good Alignment & Start Ream & Insert Posterior to FN 3 Months Healed FN & ST Fx Ambulating without Aide 7

8 Complex Combination Case Femoral Neck Stress Fx Pain in Lt Hip 52 F, RA Healthy o/w ORIF with Screws Pain at 2 wks Post Op 8

9 Removal HW & IHS Nonunion with IMN Breakage at 6 mo? Repeat IMN Breakage & Nonunion now at 18 mo? Now what? 9

10 Confirmed Nonunion Pre Op Planning Osteotomy Blade Plate Removal of Bone from IHS! 180 cc of allograft!! 10

11 4 Years Since Original Fracture 4 Weeks of Thigh Pain 2 years s/p ABP 4 weeks Later 11

12 Pertrochanteric Hip Fractures AO Classification Dynamic Hip Screw Intermediate IM Nail: Choice Reverse Oblique < 25 mm Good > 35 mm Bad Failure Rates = TAD Center Center Tip Apex Distance (TAD) Baumgaertner JBJS 77A

13 Reduction Aides Weber Clamps Spike Pushers Mallet Crutches Plate Application 2 hole Plate, Bolhofner, JOT, Screws, Koval, et al Solution: Correct Plate with Lag If lag > 80mm Standard/Long Barrel to Plate > 80mm 13

14 Unstable Pertroch Fx A Schmidt, R Kyle, et al Type Incidence Collapse Cut out I 18% 6.4mm 0% II 29% 9.9mm 1.4% III 29% 14.8mm 2.7% IV 24% 16% 17.0mm 16.0% V 8% 17.5mm 23.0% hemi, fixed angle, LLD Shortening > 15 mm: Walking Aide 83 yo Osteoporotic Female 4 part unstable IT with extension 14

15 Initial Traction Reduction Provisional Stabilization 15

16 Unstable Pattern IMHS Reverse Oblique IMHS Too Lateral, Do NOT Varus 16

17 Antirotational Screw 1 vs. 2 screws: Biomechanically similar (Kubiak) 2 screws sometimes anatomically impossible Antirotational screw increases TAD = failure Z Effect Distal IL Problems Radius of Curvature: 2800 cm Radius of Curvature: 1900 cm Problems: Short nail, Distal 1/3 Fx, Osteoporotic Bone, Ipsilateral TKA, Stress Riser/Fx Solution: Long nail, 11mm, Proximal IL Complex Pertrochanteric Pattern 17

18 66F, Low Energy Fall Traction Reduction Basicervical Neck complex IMN Comminuted Medial reconstitution Reverse Oblique Lateral fixed angle Coronal Fracture Trochanter complex IMN Create Channel for Fibular Strut Inferior Posterior 18

19 Insert Fibular Strut Allograft Posterior Inferior Assemble Plate Basicervical Neck length restored Comminuted Medial reconstitution with fibular strut Reverse Oblique Lateral fixed angle locked plate Coronal Fracture Trochanter multiple fixed screws 19

20 Subtrochanteric Fractures 20

21 Correct Rotational Alignment Fracture Reduction Start Site Universal Start Site Medial to GT AP In line with Neck - Lat 21

22 Ream Nail Insertion Proximal Interlock 22

23 Final Proximal Interlock Distal Interlock Distal IL 23

24 Atypical Femoral Fractures Short oblique fracture pattern Thickened cortices Prodromal pain symptoms 50% Bilateral Associated with 5-6 years bisphosphonate Tx: IMN > Plate Problem - IMN Diameter Visualize Image NOT Listen to Chatter Ream too Little Unstable Ream too Much Remove Cortical Bone 24

25 Traction Reduction Start Site Universal Start Site Reduce & Insert Guide Pin Finger Reduction Aide & Pin Inserter Spike Pusher Schantz Pins 25

26 Final Screw Insertion 26

27 Nail Complications 67 F, MVA Polytrauma with Right Femoral Fracture Post op XR 27

28 2 wk Post op XR Recheck injury fem neck 28

29 Nail Entire Femur Reduce Fx Risk 78 F, Fall Down Stairs Mid diaphyseal femur fx Ipsilateral tibial plateau fx Distal radius fx 29

30 92 F, 6 mo Prior IT IMN Healing Stress Fracture Stress Reaction Chronic Attempt to Heal IMN Entire Femur 30

31 Conclusions Obtain Correct Mechanical Alignment IMN vs Plate vs Arthroplasty Supplementation Mechanical, Vitamin, Medical Allow for Early WB Thank You 31

32 Michael Suk, MD JD MPH FACS Chairman Department of Orthopaedic Surgery Heal. Teach. Discover. Serve Other financial or material support from a company or supplier Stryker (Education Consultant); Synthes (Institutional Support) Medical/Orthopaedic publications editorial/governing board American Journal of Orthopaedics Geriatric Orthopaedic Surgery & Rehabilitation Journal of Trauma Management and Outcomes Military Medicine Board member/committee appointments for a society. American Academy of Orthopaedic Surgeons Board of Specialties Societies American Association of Orthopaedic Surgeons Political Action Committee Orthopaedic Trauma Association Health Policy Committee (Chair) No potential conflicts with this presentation Periprosthetic fractures above TKA not uncommon (0.3%- 2.5%) High stress zone between metaphyseal bone of the distal femur and the femoral component Tend to be older patients but younger patients receiving arthroplasties Anticipate an increased of periprosthetic fractures 1

33 Elderly patients with comorbidities High stress adjacent to implants Poor bone quality No endosteal blood supply if cemented stem Limited bone stock distally Arthroplasty Trauma 2

34 Nonunion 9% Fixation failure 4% Infection 3% Revision surgery 13% Herrera DA et al, Acta Orthop 79(1):22-27 Type I Undisplaced and well fixed prosthesis Type II Displaced with well fixed prosthesis Type III Displaced with loose prosthesis Lewis and Rorabeck (1997) Consider bracing and nonweightbearing 3

35 No metaphyseal bone loss Revision TKA with long-stemmed prosthesis Metaphyseal bone loss Structural allograft composite prosthesis or distal femoral replacement Distal Fixation Design of component Cruciate sparing Cruciate substituting Poor bone quality and quantity Long lever arm Good quality bone Internal fixation (conventional plate, IM nail or locked plate) Poor quality bone with metaphyseal comminution Good sized distal fragment IM nail or locked plate Small distal fragment locked plate (+/- strut allograft) 4

36 Restore axial alignment and length Stable fixation ROM as soon as possible Return to preinjury mobility Maintain fracture environment suitable for osteosynthesis Operative treatment best accomplishes these goals Is the notch open or closed? If open, is it large enough? Narrow notch and closed box seen in posterior stabilized knees Replaced by Locked plates The expected outcome 5

37 Valgus Deformity When there is a problem, It is loss of alignment and delayed union Provides rigid, fixed angle fixation Can be used in minimally invasive way Applicable to most long bone periprosthetic fracture situations 6

38 Critical Know the design Plan fixation 7

39 8

40 Stable distal fixation is key to successful ORIF Fracture pattern and type of arthoplasty (CR or PS) influences implant choice Retrograde nailing is adequate for fractures with adequate distal bone stock For PS knees of those with short distal fragments, plating is recommended Heal. Teach. Discover. Serve 9

41 11/26/2012 The Elderly patient with acetabular fractures A Challenging group Amir Matityahu, MD Associate Prof of Orthopaedics UCSF and SFGH Department of Orthopaedic Surgery Elderly population growing in size MVA survival greater Elderly are surviving with more complex chronic illnesses Elderly more active It is not true that Elderly acetabular fractures do not happen Commonly U.S. National Trauma Database % of all acetabular fractures are in patients > 65 years old Acetabular Fractures Total N = 9560 Matityahu, M, MD and Marmor, M, MD, OTA 2009 Age < 65 Age Elderly Acetabular Fx 1

42 11/26/2012 Who are these patients? NTDB <65 65 P Value N Male 71 % 58% < Mechanism Fall 18% 61% MVA 55% 25% < GCS <13 18% 22% <0.001 Open fracture 1.81% 0.49% Systolic BP <90 14% 17% Lower Energy, Higher Complications Acute In-Hospital Complications? Elderly Acetabular Fx <65 65 P Value N Cardiac Arrest 3% 5% 1.75x Renal Failure 2% 6% 3x Death in house 1.5% 5% 3.3x Lower Energy, 3.3 x Rate of Mortality NTDB , Matityahu, et al, 2009 OTA 1 year mortality? Elderly Acetabular Fx 25% Mortality in one year 18% conversion to THA at 2.5 years average Does ORIF of Geriatric Acetabular Fractures Lead to Hip Arthroplasty and Poor Midterm Outcomes? Robert V. O Toole, MD and Emily Hui, MPH, OTA

43 11/26/2012 Discharge Location <65 65 N SNF 5% 27% Home 58% 19% Nursing Home 2% 12% Elderly Acetabular Fx Lower Energy, Need more services NTDB Risk of Mortality in Acute Period Elderly Acetabular Fx 3.8 x risk of mortality 3.7 times increased odds of complications Need More Post Discharge Services NTDB Results Impact of Aging on the Results of ORIF Acetabular Fractures Patient age by decade G&E Elderly Acetabular Fx E LeTournel, R Judet, Fractures of the Acetabulum, Springer,

44 11/26/2012 Elderly Acetabular Fx Impediments to an Anatomical Reduction Osteopenia Comminution Posterior Wall Fracture Dome Impaction Assoc femoral neck fx Assoc femoral head fx Delayed Surgery Morbid Obesity Previous Hip Arthrosis CASE 71 year old male fall from bicycle ORIF and THA Treatment Options ORIF and possible later THA ORIF and will be OK? Leave it alone He ll do great 4

45 11/26/2012 Stoppa - Anterior intra-pelvic approach Treat - dome impaction reduction through fracture and can Buttress medial impaction Now 74 years old 3 years post op Published Outcomes Author Year N Good & Excellent Fair &Poor Helfet % 11% Stoll % 37% Anglen % 40% Wolinsky % 23% Moed % 11% TOTALS 75% 25% 5

46 11/26/2012 Percutaneous Fixation of acetabular fractures in the elderly displaced acetabular fractures treated 4% attempted reduction and percutaneous fixation 13 older patients (avg 66) Medical problems Expected to develop DJD Anatomic reduction not goal Starr AJ, et al Results Group I (n=13) All reduced within 5mm Starr AJ, et al All fractures healed No wound complications Avg Harris Hip score 84 30% - THR through a standard approach Unstable hip When to ORIF? Displaced fracture through dome Intrapelvic displacement Femoral head intact Able to get a adequate reduction Reconstruct columns for possible future THA 6

47 11/26/2012 Worst Patient for only ORIF Impaction of the dome Severe Comminution in osteoportic bone ~ The Smashed, Soft acetabulum Has posterior wall with impaction or comminution Combined with Neck or head fractures Results of THR after ORIF 63 patients follow-up 9.6 years Ten year survival 87% for acetabulum 84% for femur 0/22 (0%) uncemented acetabular components had loosening Weber, Berry and Hamsen, JBJS, 1998 Results of acute ORIF with THA Author Year N G-E Results Notes Mears % Sermon % 8% revised Moushine % Herscovici Not reported Hip score % with multiple hips dislocations DATA IS ALL OVER THE PLACE, NUMBERS ARE SMALL, CONCLUSIONS SHOULD BE TAKEN AS OPINION 7

48 11/26/2012 Acetabular fracture acute Cup Fixation tips Fix the columns and posterior wall first Plates & Screws Use multi-screw or revision Cup if needed Use Lag Screws Through Cup 78 year old female fell down stairs CT 8

49 11/26/2012 Column fixed with Screw, multi-hole cup 73 year old obese female. MVA Options - THA and ORIF 9

50 11/26/2012 Immediate Post op 2 years post op Conclusion Treatment patients with acetabular fractures in the acute phase is possible ORIF or PCP all fractures if possible This will be either final treatment or create columns to place multihole acetabular cup Follow-up with THA if needed Acute combined ORIF and THA if Neck/head fractures Previous hip arthrosis Thank You 10

51 11/26/2012 Proximal Humerus Fractures Samir Mehta, MD Chief, Orthopaedic Trauma & Fracture Service Hospital of the University of Pennsylvania The Hip Fx of the Upper Extremity The Ice Cream Fell off the Ice Cream Cone 1

52 11/26/2012 The Ice Cream Fell off the Ice Cream Cone Proximal Humerus Fx s 2 nd most common UE fx (after DRFx) 3 rd most common in > 65yo (hip fx, DRFx) Increasing epidemic (aging population) Proximal Humerus Fx s Mechanism: Fall / = 2-3 Bone quality is very poor (osteoporotic: eggshell) Most can be Rx ed Nonop (~ 85-90%) 2

53 11/26/2012 Issues Exposure demanding Osteopenia commonplace Implants imperfect Outcome unpredictable Blood Supply Major: Arcuate artery Damage may lead to AVN Anterior humeral circumflex artery Careful medial dissection Radiographic evaluation AP of the proximal humerus Y-view (transscapular lateral) Axillary view 3

54 11/26/2012 Radiographic evaluation Radiographic evaluation CT scan Neer s Classification Displacement >1cm >45 degrees 4

55 11/26/2012 Classification AO Anatomic Parts Articular segment Greater tuberosity Supraspinatus Infraspinatus Teres minor Lesser tuberosity Subscapularis Shaft Biceps Tendon Long head of biceps Surgical landmark: interval between greater tuberosity and lesser tuberosity Sometimes torn 5

56 11/26/2012 Head Varus Common Deformity/Displacement Extension Greater tuberosity Posterior Superior Treatment Goals Obtain & maintain satisfactory REDUCTION Allow early progressive ROM Achieve healing Restore FUNCTION! Treatment Considerations Fracture-related Severity of bone injury Vascularity Integrity of cuff Patient-related Functional Osteopenia Medical comorbidities Associated injuries 6

57 11/26/2012 CRPP ± IF IMN ORIF 7

58 11/26/2012 Goals of Surgical Fixation REDUCTION Restore the head - shaft angle Medial buttress calcar Undo the extension Stable fixation Early progressive ROM Approaches for ORIF Arthroplasty: Hemi-/Reverse 8

59 11/26/2012 Complications after ORIF (fixed angle device) Up to 44 % n= Complication Sudkamp N et al % Brunner F et al % Owsley KC, GorczycaJT % Meier RA et al % Fankhauser F et al % Complications Intraarticular hardware / screw cutout Failure of fixation Infection Malunion Axillary nerve injury Rotator cuff impairment Impingement Nonunion Osteonecrosis Stiffness Why? Anatomy High deforming forces: varus, inferior shear Comminution gradual collapse after initial reduction Osteopenia Impaction Implant Fixed angle, unicortical 9

60 11/26/2012 Why? Surgeon Lack of REDUCTION (medial buttress / calcar) Penetration of joint Lack of fixation to counteract varus/valgus forces Fixation not stable to start early ROM (augmentation using cuff) Patient Compliance Low bone density Systemic diseases Medications Indications for Internal Fixation Classically Two-part unstable Three-part in young to middle age Four-part in young patients Valgus impacted four-part 10

61 11/26/2012 Indications for ORIF Recent Young or old 3 or 4-part if large enough articular fragment Good enough bone quality for ORIF Have hemiarthroplasty in the room just in case Predictor of BMD and ORIF Success AP radiograph Adjust for magnification Cortical thickness of level = answer <4mm = nonsurgical, suture fixation, or hemiarthroplasty >4mm = necessary for standard screw purchase Predictor of BMD and ORIF Success AP radiograph Adjust for magnification Cortical thickness of level = answer <4mm = nonsurgical, suture fixation, or hemiarthroplasty >4mm = necessary for standard screw purchase 11

62 11/26/2012 Deltopectoral Exposure Classic approach Deltoid frustrating Helpful tips: Open RC interval Release part of deltoid origin Abduct and IR arm Deltoid Split Exposure Good for plate position and screws Axillary N. exposed Minimal problems Gardner et al. JOT 2008 Difficulty converting to hemiarthroplasty Robinson JOT 2007 Reduction Techniques: Comminuted Tuberosities Reduce head to shaft Use sutures to reduce tuberosities K-wire if possible May use plate to buttress GT 12

63 11/26/2012 Articular Surface Reduction If head is very unstable Pin to glenoid Remember You CANNOT move arm until wires removed Small plate over LT or surgical neck fx +/- leave in Reduction Tricks Based on fixation Osteoporotic Balance reduction and healing potential Avoid displacing medial hinge Elderly Impacted 13

64 11/26/2012 Tuberosity Fixation Sutures for reduction Sutures for fixation Tendon Nonresorbable Beware of Fiberwire Thread through plate prior to placing Plate Positioning Use references Guide Level of kickstand screws K-wire into place Initial screw oblong hole Cortical Adjust Avoid Acromial Impingement Too high Check fluoro with arm abducted Newer versions lower But no GT buttress 14

65 11/26/2012 Cortical screw reduce plate to bone Oblong hole Locking screws Periarticular Shaft +/- locking Screws Sphere Avoid Screw Articular Penetration Fluoro perpendicular to wire May supplement with depth gauge Live fluoro when finished Plain films intraop Void filler Autograft Allograft Calcium sulfate Tricalcium phosphate Augments 15

66 11/26/2012 Long Head Biceps Can be beaten up If any question, tenodese Suture to Plate Surrounding tissues Pitfalls Not restoring calcar Not restoring sagittal plane Not getting kickstand screws Not getting long enough screws Too long screws Plate malposition Not securing tuberosities JOT pt followed to healing Locked plating Outcomes Age Sex Fx type Cement augmentation Medial support 16

67 11/26/2012 Top Ten List 1. Check screw lengths 2. Medial Calcar 3. Augmentation with Cuff 4. Use Image Intensifier 5. CRPP is an option 6. One shot 7. Early ROM 8. Do not penetrate articular surface 9. Head / Shaft Angle 10. Challenging Samir Mehta, MD Chief, Orthopaedic & Fracture Trauma Service samir.mehta@uphs.upenn.edu 17