9/24/2015. Nailing IT Fractures: Long vs. Short Technique Tricks. Conflict of Interest. Short vs. Long Hip Nail

Transcription

1 Nailing IT Fractures: Long vs. Short Technique Tricks Cory Collinge, MD Professor of Orthopedic Surgery Vanderbilt University Medical Center Nashville, TN Conflict of Interest Consultant: Smith & Nephew, Biomet, Stryker Royalty: Smith & Nephew, Biomet Advanced Orthopedic Systems, Synthes Editorial Board: J Ortho Trauma, JBJS BOD: Foundation for Orthopedic Trauma First Generation Gamma Short vs. Long Hip Nail Large, straight nail Evolving technique 1

2 Short vs. Long Hip Nail First Generation Gamma Periprosthetic fracture Later Generation Hip Nails Short vs. Long Hip Nail Improved nail design Improved techniques Short vs. Long Hip Nail Retrospective cohort study >65 yo IT hip fractures Long or short hip nail Kleweno et al. J Ortho Trauma,

3 Short vs. Long Hip Nail Reoperations Short 5.0% (13/219) Long 5.9% (17/340) Kleweno et al. J Ortho Trauma, 2015 Fracture at end of nail > reoperation Short 2.7% (6/219) Long 1.5% (5/340) (p=0.35) Short vs. Long Hip Nail Short Long OR time (m) EBL No difference Mortality No difference Kleweno et al. J Ortho Trauma, 2015 Short vs. Long Hip Nail Literature review/ analysis Kanakaris et al. J Ortho Trauma, 2015 Long or short? Lack of robust evidence Little difference 3

4 Short vs. Long Hip Nail Literature review/ analysis Kanakaris et al. J Ortho Trauma, 2015 Lock or no lock? Lack of robust evidence Little difference Short vs. Long Hip Nail Personal opinion level 5 ½ evidence Stable IT fractures short or long Unstable IT fractures probably long with locks Subtroch long with locks Modern Hip Nailing Current standard for IT hip fractures Failure rates 10 20% Mortality 25% 4

5 Keys to Success Reduction Starting point path Reamer Understanding of nail geometry Locking PRN Fracture table Traction Reduction Usually 90% effective Reduction 5

6 Reduction Other 10%... Reduction Other 10%... Reduction Otherwise. 6

7 Entry Angle Really? Not all nails are the same Entry Angle Entry Angle J Orthop Trauma, January 2005 Volume Tip of GT Varying geometries applied through different portals Will deformity ensue? 2 3 medial 2 3 lateral 7

8 Entry Angle J Orthop Trauma, January 2005 Volume Entry Angle J Orthop Trauma, January 2005 Volume Tip or lateral insertion leads to varus deformity, especially in straighter nails. Entry Angle J Orthop Trauma, January 2011 Volume Radiographic study of entry point Measured tip of GT to perfect EP 6 bend nail 8

9 Entry Angle J Orthop Trauma, January 2011 Volume Marked variability Ideal entry point averaged 3mm medial to the tip of the greater trochanter but varied widely. Entry Angle J Orthop Trauma, January 2011 Volume Radiographic study of entry point Entry Angle 9

10 Femoral Bow Nail femur mismatch Femoral Bow J Orthop Trauma January 2014 Volume 28 Issue 1 p 6 9 Mean ROC anterior cortex is 145cm Femoral Bow Factors affecting nail position Fracture type Reduction Insertion site Guide wire insertion technique Reaming Canal size and bow (deflection) Nail material Nail geometry 10

11 Femoral Bow Implant makers have decreased the ROC e.g. Smith Nephew InterTAN (200cm > 150cm) Intra op lateral Xray: ad/ cd = % Femoral Bow Collinge et al. Comparison of distal hip nail position: 200cm vs. 150cm radius. J Ortho Trauma, 26, , 2014 Femoral Bow 200cm ROC: Cortical abutment 11

12 Femoral Bow 200cm ROC: Fracture Cohorts Gp 1: 26 pts with 200cm nail Gp 2: 32 pts with 150cm nail Gp 1 (200 ROC) Gp 2 (150 ROC) AP Nail Position Femoral Bow Midline or Posterior Anterior Abutment Fracture % 16% 4% % 3% 0% *P =0.02 *P <0.001 Compound ROC Distal femur kick Femoral Bow 2000 Old Nail

13 A Case or 2 85 yo man fell at country club 13

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15 88 yo woman fell at church Oh *#&, I barely pulled on it! Options Have a good cry and then. Calcar replacing hemi? Not available Wait an hour+, change table/reposition? Wake her up and reschedule next day? Continue nailing? Other?? 15

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20 Summary Long or short? Probably go long and lock for unstable patterns Know your key points Know your nail well 20

21 Thank You T Shit. Case 3 21

22 Traction. A few pins, some pulling & a little better but still shit. 22

23 5 mos. 23