Evidence based medicine

The presentation discusses evidence based medicine in the stream of Orthopaedics. Here I have discussed a case of Ipsilateral Intertronchanteric and Femoral shaft Fracture and its various treatment modalities. The presentation was done at J.N. Medical College Belagavi, India. Lets share, discuss and keep learning.

1. EVIDENCE BASED MEDICINE PRESENTER: DR. MURUGESH M KURANI DEPARTMENT OF ORTHOPAEDICS, J N MEDICAL COLLEGE, BELAGAVI

2. WHAT IS EBM? Evidence-based medicine (EBM) is the term used to describe the integration of the best available research evidence with clinical judgment and experience as applied to the care of individual patients.

3. EBM Levels Of Evidence Pyramid

4. So In Clinical Practice, TREATMENT OPTIONS DISEASE

5. HISTORY Name - ABC Age – 30YRS Sex - Male Address – BADAS (KH), BELAGAVI Occupation - FARMER

6. CHIEF COMPLAINTS Pain on right HIP and middle 3 rd of thigh Swelling on right HIP and middle 3 rd of thigh

7. HISTORY OF PRESENT ILLNESS H/O road traffic accident b/w 4 wheeler and a 2 wheeler, patient being 2 wheeler rider hit by a 4 wheeler and sustained injury over right hip and middle thigh. Unable to bear weight on right lower limb after the fall. No H/O LOC, vomiting, ENT bleed, convulsions.

8. PERSONAL HISTORY Diet : Mixed Appetite : Normal Sleep : Undisturbed Bowel & Bladder : Normal and regular Habbit : no addiction

9. Past history No H/O DM2/HTN/Asthma/TB Family history Not significant Vitals BP : 126/80 mm Hg Pulse : 88 /min Respiratory rate : 24 cycles/min SpO2 : 100%

10. LOCAL EXAMINATION INSPECTION Right lower limb is externally rotated Swelling and deformity seen over right HIP and middle thigh No muscle wasting No visible scars or sinuses PALPATION All inspectory findings were confirmed Local rise of temperature present Tenderness and bony deformity present over right hip and mid thigh Restricted movements at right hip joint

11. Pelvic compression test was negative Chest compression test was negative B/L Toe movements + Distal pulses were felt b/l and equally Motor and sensory examination was within normal limits

12. PRE OP X RAYS

13. RIGHT SIDED IPSILATERAL INTERTROCHANTERIC (31-A1) WITH FEMORAL SHAFT (32-A2) FRACTURE.

14. CLASSIFICATION

15. CLASSIFICATION FOR IT FRACTURES 1. BOYD AND GRIFFIN 2. EVAN’S 3. TRONZO 4. AO CLASSIFICATION

16. CLASSIFICATION FOR FEMUR SHAFT FRACTURES WINQUIST AND HANSEN AO CLASSIFICATION

17. IPSILATERAL IT WITH FEMUR SHAFT FRACTURE

18. INTERNAL FIXATIVE DEVICES DYNAMIC HIP SCREW and COMPRESSION PLATE 2. DYNAMIC HIP SCREW and RETROGRADE NAILING 3. LONG PROXIMAL FEMORAL NAILING

19. EVIDENCES

20. Article 1 J Orthop Trauma. 2008 Feb;22(2):102-6. doi : 10.1097/BOT.0b013e318162a0d2. wolters kluwer “ Functional outcome of ipsilateral intertrochanteric and femoral shaft fractures ”

21. Ipsilateral intertrochanteric and femoral shaft fractures treated with a reconstruction nail versus a sliding hip screw and retrograde nail. RESULT: The average time to follow-up was 49.6 months. Functional outcome was significantly better in the reconstruction nail group for the role emotional (P=0.001) and mental component scores (P=0.016) of the SF-36. This group also scored better on the LEFS, although not reaching statistical significance (P=0.099).

22. CONCLUSION: For most outcome measures, no significant differences in functional outcome scores were observed between the 2 treatment groups. The results of this study suggest the need for a randomized controlled trial with a larger sample size to more definitively compare the 2 fixation constructs.

23. Article 2 Orthopaedic Surgery (2012), Volume 4, No. 1, 41–46 “ A comparative study of ipsilateral intertrochanteric and femoral shaft fractures treated with long proximal femoral nail antirotation or plate combinations ”

24. METHODS: Between March 2004 and April 2009, 23 patients with ipsilateral intertrochanteric and femoral shaft fractures were treated with PFNA-long or plate combinations . The patients were divided into two groups. Group I contained 13 patients who were treated with dynamic hip screws (DHS) combined with compression plate fixation . The 10 patients in Group II were treated with PFNA-long.

25. RESULTS: The average follow-up was 17.8 and 16.8 months for Groups I and II, respectively. The average union time for intertrochanteric fractures was 17.4 and 16.6 weeks in Groups I and II, respectively, and for femoral shaft fracture 22.2 and 21.5 weeks , respectively. There were nine good, two fair, and two poor functional results in Group I , and eight good, one fair, and one poor in Group II . There was nonunion of two femoral shaft fractures in Group I and one in Group II.

26. CONCLUSION Both treatment methods achieve satisfactory functional outcomes in patients with ipsilateral intertrochanteric and femoral shaft fractures. PFNA-long is the better choice for the treatment of complex fractures , having the advantages of minimal exposure, reduced perioperative blood loss, and achievement of biological fixation of both fractures with a single implant.

27. Article 3 http://bjjprocs.boneandjoint.org.uk/content/87-B/SUPP_III/310.4 Orthopaedic Proceedings “ FUNCTIONAL OUTCOME OF IPSILATERAL INTERTROCHANTERIC AND FEMORAL SHAFT FRACTURES ”

28. CONCLUSION: Despite having sustained more severe injuries, the sliding hip screw with retrograde nail group showed a trend towards better outcome as compared to the group treated with the reconstruction nail.

29. Article 4 A meta-analysis of 659 cases Acta Olthop Scand 1996; 67 (1 ): 19-28 “ Concurrent ipsilateral fractures of the hip and femoral shaft ”

30. RESULT: Locked intramedullary nails ( cephalomedullaty nails) yielded results which were superior to combinations of plates or unlocked nails and separate hip screws.

31. Post OP XRAY AP and LAT views

32. Dynamic hip screw for intertrochanteric with plating for shaft can provide easy fixation and favourable results have been reported but is associated with increased blood loss and periosteal stripping of the femoral shaft, extensive surgical dissection.

33. Retrograde nailing for shaft with Dynamic hip screw for intertrochanteric fractures seems to be an attractive treatment modality preventing periosteal stripping and extensive surgical dissection but studies shows that retrograde nailings are associated with articular damage and stiff knee post operatively.

34. Long proximal femoral nail for fixation of both intertrochanteric and shaft promises stable fixation and better osseous healing. Intra- Medullary implant itself acts as a buttress to prevent excessive fracture collapse and shaft medialization . It also offers the advantage of a reamed and unreamed implantation technique, high rotational stability of the proximal fragment, and the possibility of static or dynamic distal locking. Almost all the load is transferred to the nail and negligible portion to the medial femoral cortex.

35. Thus, long proximal femoral nail is a good option for the treatment of complex fractures like these, with the advantages of closed antegrade nailing with minimal exposure, reduced perioperative blood loss, and biological fixation of both fractures with a single implant.

36. TAKE HOME MESSAGE Long PFN is a better fixation system for ipsilateral intertrochanteric and femoral shaft fracture with less surgical trauma, less operative time, less blood loss, early rehabilitation, possibility of early weight bearing. Surgical expertise is necessary. Surgeon preference.