5/31/2018. Ipsilateral Femoral Neck And Shaft Fractures. Ipsilateral Neck-Shaft Fractures Introduction. Ipsilateral Neck-Shaft Fractures Introduction

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1 Ipsilateral Femoral Neck And Shaft Fractures Exchange Nailing For Non- Union Donald Wiss MD Cedars-Sinai Medical Center Los Angeles, California Introduction Uncommon Injury Invariably High Energy Trauma Typically In Young Male Patient Associated Injuries Common Requires Prompt Diagnosis & Rx Introduction Incidence 3% - 5% Difficult To Manage When Displaced Timing Of Treatment Controversial Complications High In Many Series 1

2 Mechanism Of Injury High Energy Trauma Longitudinal Force Flexed & Abducted Hip Flexed Knee Resultant Femoral Neck Fracture Basilar In Location Vertical In Orientation Displacement Variable Hard To Visualize Sub-Optimal X-Rays Missed Diagnosis Literature Up To 1/3 Femoral Neck Fractures Are Missed My Case 1982 When The Femoral Neck Fracture Is Missed Treatment Options Later Become More Limited And Difficult With Outcomes Worse Dedicated Hip X-Rays & CT Scans On Initial Trauma Work-Up Decrease Incidence Of Missed Fractures 2

3 Knee Injuries Knee Injuries In 25% - 50% Patella Fractures Femoral Condyles PCL Injuries Easily Missed Pre-Op Exam Difficult High Index Of Suspicion Late Morbidity Treatment Wide Consensus That Fractures Of The Hip Should Take Precedence Over The Femoral Shaft Fracture Consequences Of The Neck Fracture Avascular Necrosis Non-Union Varus Mal-Union All Challenging To Treat Arthroplasty Unattractive 3

4 Femoral Neck Fracture Non-Displaced Fxs In-Situ ORIF Displaced Fractures Direct Anterior Approach Antero-Lateral Approach Goal Is Anatomical Reduction Treatment Alternatives Reconstruction Nail Antegrade Nail & Nail Cannulated Screws & Retrograde Nail SHS And Retrograde Nail Femoral Neck Screws And Plate Treatment Alternatives Reconstruction Nail Antegrade Nail & Nail Large Screws & Retrograde Nail SHS And Retrograde Nail Femoral Neck Screws And Plate 4

5 Treatment Alternatives Reconstruction Nail Antegrade Nail & Nail Cannulated Screws & Retrograde Nail SHS And Retrograde Nail Femoral Neck Screws And Plate Treatment Alternatives Reconstruction Nail Antegrade Nail & Nail Cannulated Screws & Retrograde Nail SHS And Retrograde Nail Femoral Neck Screws And Plate Treatment Alternatives Reconstruction Nail Antegrade Nail & Nail Cannulated Screws & Retrograde Nail SHS And Retrograde Nail Femoral Neck Screws And Plate 5

6 Treatment Anatomical Reduction & Stable Internal Fixation Of The Femoral Neck Fracture Is Mandatory Attempts To Fix Both Fractures With One Implant Have Been Unpredictable Alho A. Concurrent Ipsilateral Fractures Of The Hip & Femoral Shaft: A Meta-Analysis Of 659 Cases Acta Orthop Scand 67: 19-28, Studies 78% Motor Vehicle Accidents, Median Age 34 Yrs 1/3 rd Had Multiple Injuries ½ Had Ipsilateral Knee Injuries Femoral Neck Fracture Mostly Basilar In Location AVN Rate 3%, 99% Healed Locked Nails Gave Better Results Than Unlocked Nails or Plates Reconstruction Nails Gave Equal Results To Separate ORIF Femoral Neck & IM Nails Tornetta P, Kain M, Creevy W. Diagnosis of Femoral Neck Fractures in Patients With a Femoral Shaft Fracture J Bone Joint Surg 89: 39-43, 2007 Developed A Protocol To Diagnose A Femoral Neck Fracture In Pts With A Shaft Fx Dedicated AP Internal Rotation Plain X-Ray; 2mm CT Scan Thru Hip; & Intra-Op Fluroscopic AP And Lateral Views Prior To And After Fixation N=268 Femoral Shaft Fractures Identified 16 Associated Femoral Neck Fractures Using Protocol Conclusion: 91% Reduction In Delay in Diagnosis Compared To Year Prior To Protocol 6

7 Ostrum R, Tornetta P, Watson J, et al. Ipsilateral Proximal Femur & Shaft Fractures Treated With Hips Screws & Reamed Retrograde IM Nail Clin Orthop Relat Res 472: , 2014 N=92 40 SHS 52 Multiple Cannulated Screws All Retrograde Nail Femoral Neck Union Rate 98% Femoral Shaft Union Rate 91% Proximal Femoral Mal-Union 5% Avascular Necrosis 1% No Difference Between SHS Vs Cannulated Screws Conclusion: Independent Screw Fixation Of The Femoral Neck Fracture & Reamed Retrograde IM Nailing Leads To High Rates Of Union & Low Complication Rates Conclusions Independent Fixation Both Fractures Often Requires Open Reduction Of Neck Fx Cannulated Screws Or SHS Retrograde Locked Nailing Reconstruction Nails Only In Truly Non- Displaced Femoral Neck Fractures Illustrative Cases 7

8 46 Yr Male Involved In High Speed Motorcycle vs Auto Accident Sustaining An Open Grade IIIA Segmental Femur Fracture, Displaced Femoral Neck Fracture, & Acetabular Iliac Oblique Confirms & Complex Acetabular Fracture Obturator Oblique Pelvis Looks Bad 8

9 I & D Open Femur Fracture; Temporary Two Pin External Fixator, Direct Anterior Approach; 3 Cannulated Screws; Retrograde Nailing And Placement Of Temporary Traction Pin To Manage Acetabular Fx Post-Op CT Scan With 3D Reconstruction Shows T-Type Acetabular Fx CT Pelvis With 3D Reconstructions Show Both Column Involvement 9

10 ORIF On Profx Table Via A Stoppa Approach Courtesy Charles Moon MD Radiographs At 6 Months ROM Of Hip Degrees; ROM Knee Degrees; Healed 10

11 41 Yr Old Male Fell 15 Feet From Balcony While Intoxicated Sustaining A Vertical Femoral Neck Fracture As Well As A Grade IIIA Open Segmental Femur Fracture & Ipsilateral Patella Fracture Emergent I & D And External Fixation Of The Femur To Allow For Fixation Of The Femoral Neck Fracture 11

12 Direct Anterior Approach With Anatomic Reduction And Fixation With Two Cannulated Screws 3 Days Lateral Removal Ex Fix; Retrograde Femoral Nailing; Two Additional Femoral Neck Screws; ORIF Patella; Follow-Up At 8 Weeks On Crutches Improving ROM Hip & Knee 12

13 ROM Hip 0-90 Degrees ROM Knee 0-70 Degrees Lost To Follow-Up 24 Yr Swedish Female Working /Living In LA Related To Film Industry Suicide Attempt Following Jump From 6 th Story Apartment Building Hemodynamically Unstable Pelvis Fracture Bilateral Pneumonthorax & Multiple Rib Fractures Unstable Thoracic Spine Fracture and T-6 Paraplegia Bilateral Closed Femur Fractures Displaced Right Femoral Neck Fracture Left Supracondylar Humerus Fracture Distraction-Compression Injury & Burst Fracture T-Spine Complete T-6 Paraplegic 13

14 Bilateral Femur Fractures & Right Femoral Neck Fracture Reduction, Instrumentation, & Fusion Thoracic Spine T-2 To T- 11 Bilateral Retrograde Femoral Nailing & CRPP Of Right Femoral Neck After Spine Stabilization 14

15 Post-Op ORIF Right Femur Closed Reduction & Percutaneous Pinning Of The Pelvis POD #4 ORIF Segmental Humerus, Clavicle, & Calcaneus Post-Op Day 9 15

16 Fixation Of All Fractures By Injury Day 11 Air Ambulance Back To Sweden 7 Weeks After Injury It Is Not Enough To Stare Up The Steps; We Must Step Up The Stairs Donald.Wiss@cshs.org 16