Early Surgical Rx. Who Risks Failure? 5/16/2017. Cory Collinge, MD Vanderbilt University Nashville, TN
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1 Femoral Neck Fractures in Young Adults: What is the Standard? Cory Collinge, MD Vanderbilt University Nashville, TN Early Surgical Rx Protzman and Burkhalter. Femoral neck fractures in young adults. JBJS-Am, patients aged (Army) Mostly CRIF 59% 59% nonunions 86% AVN Who Risks Failure? What is likely to affect union? Host factors (hormones, smoking, etc. ) Intra articular injury (synovial fluid) Vascularity Fracture configuration Reduction Affected by surgeon Fixation 1
2 Who Risks Failure? Fracture orientation: vertical Friedrich Pauwels (1920 s) Biomechanical view of hip fractures Compressive vs. shearing forces Modern Modern Liporace et al. Results of internal fixation of Pauwels III vertical femoral neck fractures. JBJS-Am, patients young patients with Pauwels III Mostly CRIF 17% nonunion 30% failure rate 12% AVN 2
3 Modern Disclosure I have failed Modern Disclosure Failure is costly for the young patient Modern Modern Pauwels... Swiontkowski et al...? 3
4 Outcomes IF Femoral Neck Outcomes Zielinski et al. Femoral Neck Shortening After Internal Fixation of a Femoral Neck Fracture. Orthopedics, 2013; 36(7) Results IF of femoral neck fractures and femoral neck shortening affect patient VAS scores and functional outcomes. Outcomes IF Femoral Neck Outcomes Zielinski et al. Femoral Neck Shortening After Internal Fixation of a Femoral Neck Fracture. Orthopedics, 2013; 36(7) Results Displaced fractures and Pauwels 3 fractures shorten the most. Algorithms (e.g. MacCauley et al, JAAOS, 2006) Undisplaced femoral neck fracture (Garden I II) ORIF 4
5 Algorithms (e.g. MacCauley et al, JAAOS, 2006) Undisplaced femoral neck fracture (Garden I II) ORIF? Algorithm provided Algorithm provided? 5
6 ICL Example 6
7 What might have been done differently? What about pre operative planning? 7
8 Is evaluating this in surgery OK? What sort of evaluation is being done? 3 trauma centers 65 Pauwels III vertical neck fractures in patients <50 yo undergoing repair Exclusion: Acetabular or femoral shaft fx Arthroplasty Collinge, Beltran, Reddix, and Mir. J Ortho Trauma submitted What sort of evaluation is being done? AP and lateral Xrays 65/65 Vertical pattern apparent 30/65 (55%) Advanced imaging 2% had dynamic/ traction views 55% had CT scan (25/30 trauma scans) Collinge, Beltran, Reddix, and Mir. J Ortho Trauma submitted 8
9 Understand: Take Home Point #1 Injury Xrays Radiography: 52 yo rancher Collinge, Beltran, Reddix, and Mir. J Ortho Trauma, 2014 Understanding fracture morphology 55% of patients had CT CT provides great information Axial cuts good 2D recons very good 3D recons excellent Collinge, Reddix, and Mir. J Ortho Trauma, April
10 Fracture Fracture Morphology Morphology Confirmed vertical fracture 61 o Collinge, Reddix, and Mir. J Ortho Trauma, 2014 Fracture Fracture Morphology Morphology External rotation deformity Fracture rarely transverse Collinge, Reddix, and Mir. J Ortho Trauma, 2014 Fracture Fracture Morphology Morphology Comminution Young 95% Apex inferiorly on calcar Collinge, Reddix, and Mir. J Ortho Trauma,
11 Fracture Fracture Morphology Morphology Loss of the calcar buttress Collinge, Reddix, and Mir. J Ortho Trauma, 2014 Fracture Fracture Morphology Morphology Loss of the calcar buttress: 50% Collinge, Reddix, and Mir. J Ortho Trauma, 2014 Fracture Morphology Erosion Collinge, Reddix, and Mir. J Ortho Trauma, April
12 Fracture Fracture Morphology Morphology Fracture What Morphology else does CT offer? Quantitative CT Yields data similar to DEXA Quantifies osteoporosis Software $11,000 (Siemens) Fracture Fracture Morphology Morphology So now what? Better idea of obtaining reduction Not everyone gets the same construct (?) Buttress plating the neck? Fixed angled devices with rotational control? Modelling for Lab studies 12
13 Case Example Case Examples 1 Case Example 1 Case Example 1 Traction/ IR 13
14 Case Example 1 Case Example 1 Reduction: Take Home Point #2 14
15 Reduction Reduction Must overcome deformity and muscle forces Short External rotation Varus Reduction Reduction Ideal reduction is ANATOMIC Restores muscle lengths, levers Restores fracture stability Optimizes fractures mechanics Interdigitates bony interstices Acceptable?: <15 valgus, <10 AP NO varus is acceptable Reduction Closed Reduction Leadbetter Technique Flex the hip to 90, slight adduction In line traction with the femur While maintaining traction, IR to 45 Slowly move into slight abduction and full extension, while maintaining traction and internal rotation Lots of others 15
16 Open Reduction Heuter/ Mini Smith Pete Excellent neck exposure Open Reduction Open Reduction Traction (or not) Open Reduction Joy stick(s) Rotate Push/pull(?) Provisional fixation Bone hook pull (rotate) 16
17 FIGURE 4. A, A 16 year old female involved in a high speed motor vehicle accident. The patient sustained a left external iliac artery injury requiring emergent repair. The reduction was then temporarily held with a 3.5 mm pelvic reconstruction plate (D and E). Definitive fixation was placed percutaneously using small incisions (F and G). The bone hook prevents subluxation through the acetabular fracture. Clamps Small or mini frag plates Open Reduction of Intracapsular Hip Fractures Using a Modified Smith Petersen Surgical Exposure Molnar, Robert B; Routt, M L (Chip) Jr Journal of Orthopaedic Trauma. 21(7): , August doi: /BOT.0b013e31804a7f7f Copyright 2011 Journal of Orthopaedic Trauma. Published by Lippincott Williams & Wilkins. 49 Fixation: Take Home Point #3 Fixation Mechanical Fixation in Vertical Neck Fx < Baitner et al, Clin Orthop,
18 Fixation Mechanical Fixation in Vertical Neck Fx < = Grossman et al., OTA, 2001 Fixation Mechanical Studies Cadaveric study, multiplanar cyclic loading < < < Aminian et al, JBJS, 2007 Fixation Mechanical Studies Clinical series, 56 patients < Liporace et al, JBJS,
19 Fixation Prox Fem Locking Plate Lin et al. Proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures. Orthopedics, 2012; 35(1) 1-5. Clinical study 41 patients Mean age 47 (21 65) Fixation Prox Fem Locking Plate Lin et al. Proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures. Orthopedics, 2012; 35(1) nonunions (5%), 2 AVN requiring surgery (5%) 63% excellent and 20% good results (Harris hip) Fixation Prox Fem Locking Plate Lin et al. Proximal femoral locking plate with cannulated screws for the treatment of femoral neck fractures. Orthopedics, 2012; 35(1) 1-5. All 63% 20% 7% 10% 63%
20 Summary: Case ED Xrays 2 Summary: Case ED Xrays 2 Summary: Case CT 2 20
21 Summary: Case 2 Summary: Case 2 Summary: Case 2 21
22 Summary: Case 2 Summary: Case 2 Summary: Case 2 22
23 Summary: Case 2 Summary: Case 2 Summary: Case 2 23
24 Summary: Case 2 Summary: Case 10 mos 2 Summary: Case Lengths? 2 24
25 Conclusions Final Thoughts Femoral neck Fx in young adult Assessment Pre op planning Reduction Fixation Complication management Conclusions Final Thoughts Pauwels III femoral neck Fx in young adult We need to understand the injury better Requires a thoughtful solution Thank You 25
26 Open Reduction ORIF w/ Std. Implant + Anti-glide Plate Open Reduction ORIF w/ Std. Implant: Common mode of failure Augmentation Mir and Collinge Buttress plate for a shearing injury 26
27 Radiographic W/U Collinge, Reddix, and Mir. J Ortho Trauma, Submitted. 90% 85% Radiographic W/U Collinge, Reddix, and Mir. J Ortho Trauma, Submitted. 52% 38% Radiographic W/U Collinge, Reddix, and Mir. J Ortho Trauma, Submitted. 2% 27
28 Injury Xrays Radiography: 52 yo rancher Collinge, Beltran, Reddix, and Mir. J Ortho Trauma submitted A Rational Approach? Pre operative Assessment 28
29 Fixation Plate screw with anti rotation DHS + AR screw Double Engine Medical, China 29
![Orthopedics, Jan, 2012 Discussion? Schizophrenic Thinking schiz o phre ni a [skit suh free nee uh, freenyuh] noun 1. Psychiatry.. Also called dementia praecox.](/docs-images/78/77714758/images/30-0.jpg "A mental disorder characterized by some, but not necessarily all of the following features: emotional blunting, intellectual deteriorization, social isolation, disorganized thought and behavior,")
30 Orthopedics, Jan, 2012 Discussion? Schizophrenic Thinking schiz o phre ni a [skit suh free nee uh, freenyuh] noun 1. Psychiatry.. Also called dementia praecox. A mental disorder characterized by some, but not necessarily all of the following features: emotional blunting, intellectual deteriorization, social isolation, disorganized thought and behavior, delusions, and hallucinations. 2. a state characterized by the coexistence of contradictory or incompatible elements. 30
31 Vertical Shear Fractures of the Femoral Neck A Biomechanical Study. Baitner, Avi C. MD; Maurer, Stephen G. MD; Hickey, Derrick G. MD; Jazrawi, Laith M. MD; Kummer, Frederick J. PhD; Jamal, Joseph BS; Goldman, Sara BS; Koval, Kenneth J. MD December 2002Volume 33, Supplement 3, Pages Analysis of fracture gap changes, dynamic and static stability of different osteosynthetic procedures in the femoral neck F.A. Bonnaire, A.T. Weber Internal Fixation of Femoral Neck Fractures With Posterior Comminution: A Biomechanical Study Kauffman, Jeffrey I.; Simon, Jordan A.; Kummer, Frederick J.; Pearlman, Charles J.; Zuckerman, Joseph D.; Koval, Kenneth J. 31
32 Home > May 1996 Volume 10 Issue 4 > Relationship of Mechanical Factors to the Strength of Proxim... ===== ASP._controltemplates_oaks_journals_articleviewerusercontrol_ascx generated at 2/22/2015 8:39:00 PM ===== link tag emitted to support printing Article/Abstract Viewer User Control < Previous Abstract Next Abstract > You could be reading this...starts You could be reading the full text of this article now if you... Become a subscriber Purchase this article If you have access to this article through your institution, you can view this article in You could be reading this...ends Journal of Orthopaedic Trauma: May 1996 Volume 10 Issue 4 pp Original Article Relationship of Mechanical Factors to the Strength of Proximal Femur Fractures Fixed with Cancellous Screws Stankewich, C. J.; Chapman, Jens; Muthusamy, Raman; Quaid, Gina; Schemitsch, Emil; Tencer, Allan F.; Ching, Randy P. Journal of Orthopaedic Trauma: January 1998 Volume 12 Issue 1 pp Original Articles Predicting the Mechanical Outcome of Femoral Neck Fractures Fixed with Cancellous Screws: An In Vivo Study Weinrobe, M.; Stankewich, C. J.; Mueller, B.*; Tencer, A. F. June 2012Volume 43, Issue 6, Pages Biomechanical analysis of a novel femoral neck locking plate for treatment of vertical shear Pauwel's type C femoral neck fractures Peter J. Nowotarski, Bain Ervin, Brian Weatherby, Jonathan Pettit, Ron Goulet, Brent Norris Accepted: September 12, 2011; 32
33 Displaced Femoral Neck Fractures in Young Adults Treated With Closed Reduction and Internal Fixation Hui Kuang Huang, MD; Yu Ping Su, MD; Chuan Mu Chen, MD; Fang Yao Chiu, MD; Chien Lin Liu, MD Orthopedics December 2010 Volume 33 Issue 12 Injury Volume 28, Issue 2, March 1997, Pages <img alt="cover image" src=" class="toprightlogo" /> Paper Percutaneous cannulated screw fixation of femoral neck fractures: the three point principle C.A. Bout, D.M. Cannegieter, J.W. Juttmann Journal of Orthopaedic Trauma: February 2000 Volume 14 Issue 2 p 131 Abstracts From The 15Th Annual Meeting Of The Orthopaedic Trauma Association A biomechanical analysis of fixa on constructs in high angle femoral neck fractures Sirkin, Michael; Grossman, Mark G.; Renard, Regis L.; Sabatino, Christopher T.; Doumas, Christopher; Reilly, Mark C.; Behrens, Fred F. 33
34 The effect of moment arm length on high angled femoral neck fractures (Pauwels' III) MS LePine, WR Barfield, JD DesJardins Journal of Biomedical, 2010 file.scirp.org Journal of Trauma Injury Infection & Critical Care: September 2011 Volume 71 Issue 3 pp doi: /TA.0b013e31820e86e6 Original Article A Comparative Biomechanical Analysis of Fixation Devices for Unstable Femoral Neck Fractures: The Intertan Versus Cannulated Screws or a Dynamic Hip Screw Rupprecht, Martin MD; Grossterlinden, Lars MD; Ruecker, Andreas H. MD; de Oliveira, Alexander Novo MD; Sellenschloh, Kay Dipl Ing; Nüchtern, Jakob MD; Püschel, Klaus MD; Morlock, Michael MD; Rueger, Johannes Maria MD; Lehmann, Wolfgang MD 34
35 Figure 2 Vertically Oriented Femoral Neck Fractures: Mechanical Analysis of Four Fixation Techniques Aminian, Arash; Gao, Fan; Fedoriw, Wasyl W; Zhang, Li Qun; Kalainov, David M; Merk, Bradley R Journal of Orthopaedic Trauma. 21(8): , September doi: /BOT.0b013e31814b822e FIGURE 2. Digitalized points for constructing x y z coordinates. Copyright 2015 Journal of Orthopaedic Trauma. Published by Lippincott Williams & Wilkins. 103 Augmentation Mir and Collinge Buttress plate for a shearing injury Prox Fem Locking Plate Zielinski et al. Femoral Neck Shortening After Internal Fixation of a Femoral Neck Fracture. Orthopedics, 2013; 36(7) Results 35
36 Conclusions Prox Fem Locking Plate Zielinski et al. Femoral Neck Shortening After Internal Fixation of a Femoral Neck Fracture. Orthopedics, 2013; 36(7) The following conclusions are notable. Internal fixation of femoral neck fractures results in permanent physical limitations Median femoral neck shortening was 1.1 cm Femoral neck shortening decreased gait velocity and seemed to impair gait symmetry and physical functioning Age, weight, and Pauwels classification were risk factors for femoral neck shortening Fixation Mechanical Studies Mechanical Fixation in Vertical Neck Fx < Koval, Clin Orthop, 1999 Fixation Mechanical Studies Mechanical Fixation in Vertical Neck Fx < = Grossman et al., OTA,
37 Fixation Mechanical Studies Cadaveric study, multiplanar cyclic loading < < < Merk, JBJS, 2007 I have failed. Disclosure 37
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