Intertrochanteric fracture surgical option

A brief presentation about different kinds of implants for IT fracture and its indications.

1. INTERTROCHANTERIC FRACTURE Surgical Treatment Options Nguyen Q T Q, MD Department of Orthopedic Surgery Hue National Hospital

2. Fracture maps Extracapsular Between the greater and lesser trochanter

3. Epidemiology 50% of all hip fractures Elderly patient: low energy fall + osteoporosis  Female-male ratio 2:1 20-30% mortality first year High failure rate 4-12%

4. Anatomy Trabecular bone Calcar femorale  

5. Classification Stable Unstable

6. Surgery Treatment Plate and screw construct Nail construct  External fixation Arthoplasty

7. Blade plate Compare to Sliding implant Cut-out: 13% vs 4% Non union: 2% vs 0.5% Implant breakage: 14% vs 0.7% Re-operation: 10% vs 4% Higher mortality, residual pain, impaired mobility The continued use of Fixed nail plates cannot be justified

8. Sliding HS Dynamic compression Dynamic interfragmentary compression Gold standard for hip fracture 1980's – 2000 1955 - Schumpelick and Jantzen

9. Sliding HS Dynamic compression Anterior spike mal-reduction  

10. Sliding HS Dynamic compression Collapse

11. Sliding HS Dynamic compression Medialization of the shaft up to 90% (Rale et al 1993) Still useful for A1 stable fracture (Parker et al – meta analysis)

12. IM Nail The sliding hip screw is the better implant

13. IM Nail First generation of Gamma nail Early mobilization, full weight bearing Unstable fracture There was no evidence for a reduced failure rate with IMN in unstable trochanteric fractures.

14. IM Nail The gamma nail cannot be recommended for routine use in trochanteric fractures until the problem of femoral shaft fracture is resolved. SHS lower complication rate Different types of intramedullary nail produce similar results? Intramedullary nails have advantages for selected fracture types?

15. IM Nail Femoral shaft fracture risk with Gamma nails have been resolved 

16. IM Nail CMN in unstable IT fractures: best results in functional outcomes, 12 month mortality, lower revision rates compared to SHS

17. IM Nail Impaction class Dynamic compression class   Reconstruction class integrated

18. Locking Plate 4.5 LCP proximal femur plate - Synthes Proximal Femur Plate – Hrorrtho PERI-LOC 4.5mm Proximal Femur Locking Plate – Smith Nephew

19. Locking Plate PFLP was not an appropriate treatment for trochanteric fractures PFLP is not universally effective in treating IT fractures. Femoral locked plate (PFLCP) can give good healing, with a limited occurrence of complication

20. Arthroplasty Early walking + full weight bearing Reduced pressure ulcer + pulmonary infection No decrease mortality rate Option for patient >75 yo with unstable fracture ​

21. Arthroplasty Total or bipolar Dislocation rate: 12% vs Hemi Geiger et al Arch of Orthop trauma Surgery 2007 Abandon THA as the luxation rate was higher than hemiarthroplasty

22. Arthroplasty Cemented or cementless The cementation: cement embolization, non-union, varying cement mantle thickness non-union greater trochanter progressive radiolucent line 

23. Arthroplasty Cemented or cementless Cementless : early mobilization, acceptable functional results, low implant loosening rates, shorter surgery time, lesser blood loss, lower perioperative mortality rate Satisfactory results: early weight bearing, early rehabilitation, low rate of complication

24. Arthroplasty versus internal fixation Internal fixation: preferred method for elderly unstable IT fractures, even severe osteoporosis  Nail: equal clinical outcomes  Arthroplasty: more expensive, operating time, blood loss, higher mortality rate No functional benefit over internal fixation

25. Summary Implant selection Blade plate: abandoned for IT fracture DHS: still useful for A1 stable fracture, not recommend in A3 fracture or A2 unstable fracture IM nail:  first option for unstable fracture Arthroplasty: preexisting OA, pathologic fracture, severe comminution, severe osteoporosis, salvage procedure Locking plate: Piriformis or trochanteric extension, narrow intramedullary canal, pulmonary injury, abductor preservation 

26. Thank You!!