Intertrochanteric fractures of the femur

Presentation for the PG Clinic at Nanavati Hospital, Mumbai

1. INTERTROCHANTERIC FRACTURES OF THE FEMUR DR. RAJIV MARIO COLA Ç O RESIDENT - ORTHOPAEDICS DEPARTMENT OF ORTHOPAEDICS DR. BALABHAI NANAVATI HOSPITAL, MUMBAI

2. INTRODUCTION Extracapsular Occur in the region between the greater and the lesser trochanters of the femur; often extending to the subtrochanteric region Part of PERTROCHANTERIC fractures – extend from the extracapsular basilar neck region to the region along the lesser trochanter before the development of the medullary canal.

3. HISTORY Cooper – Described an intertrochanteric fracture in his treatise of 1851 - recommended treatment was "moderate extension and steady support of the limb in its natural position.“ He recognized that extracapsular fractures united, whereas intracapsular fractures did not. His treatment consisted of bed rest, followed by the use of crutches and a cane, and then an elevated shoe, all in an attempt to save the patient's life if not the limb.

4. HISTORY Dupuytren , Malgaigne , Velpeau   Royal Whitman (1902) first reported on the reduction of fractures with abduction, internal rotation, and traction under anesthesia with immobilization in a spica cast from the nipple line to the toes.

5. HISTORY Ledbetter - heel-and-palm test for adequate reduction, saying that "after the leg has been brought down in the measured degree of abduction and internal rotation, the heel of the injured leg is allowed to rest on the outstretched palm. If the reduction is complete, the leg will not exert itself. Should there be no interlocking of the fragments, however, the leg will slowly rotate externally.“ Langenbeck attempted internal fixation of the reduced fracture in 1850 using an intramedullary nail.

6. HISTORY Jewett in 1930 introduced the Jewett nail to provide immediate stability of fracture fragments and early mobilization of the patient 1950 – Earnest Roll in Germany – first to use sliding screw and Pugh and Badgley introduced sliding nail with trephine tip in USA

7. HISTORY 1962 – Massie – modified sliding devices to allow collapse and impaction of the fragments. Richard manufacturing co. of USA produced Dynamic Hip Screw 1966 – Kuntschner and later in 1970 Enders introduced the condylocephalic intramedullary devices 1984 – Russel Taylor reconstructed intramedullary nail for pertrochanteric and subtrochanteric fractures 1992 – Halder and Williams introduced the Gamma nail

8. EPIDEMIOLOGY Varies from country to country. United States – 150,000 fractures annually with an annual incidence of 63 and 34 per 100,000 for elderly males and females respectively India - Rising because of increasing number of senior citizens with osteoporosis. By 2040 the incidence is estimated to be doubled. In India the figures may be much more.

9. FACTORS CONTRIBUTORY TO THE DEVELOPMENT OF AN IT FRACTURE Advancing age Increased number of comorbidities Increased dependency in activities of daily living History of other osteoporosis-related (fragility) fractures

10. ANATOMY Occur in the region between the greater and lesser trochanters of the proximal femur, occasionally extending into the subtrochanteric region Since they occur in cancellous bone with abundant blood supply – no problems of non-union and osteonecrosis

11. ANATOMY Deforming muscle forces will usually produce shortening, external rotation and varus position at the fracture

12. Abductors displace Greater T rochanter laterally and proximally Iliopsoas displaces Lesser T rochanter medially and proximally Hip flexors, extensors and adductors pull distal fragment proximally ANATOMY

13. MECHANISMS OF INJURY YOUNGER INDIVIDUALS – High energy (relatively rare) - injury such as a motor vehicle accident or fall from height More common in men less than 40 years of age

14. MECHANISMS OF INJURY 90% of intertrochanteric fractures in the elderly result from a simple fall The tendency to fall increases with patient age and is exacerbated by several factors, including poor vision, decreased muscle power, labile blood pressure, decreased reflexes, vascular disease, and coexisting musculoskeletal pathology.

15. MECHANISMS OF INJURY Most fractures result from a direct impact to the greater trochanter area Low energy falls from a standing height – approximately 90% of community hip fractures in patients more than 50 years of age with a higher proportion of women

16. CUMMINGS’ FACTORS DETERMINING FRACTURE AT THE HIP The faller must be oriented to fall or “impact” near the hip Local soft tissues must absorb less energy than necessary to prevent fracture (inadequate soft tissue – muscle/fat coverage) Protective responses must be inadequate to reduce the energy of the fall beyond a certain critical threshold Residual energy of the fall applied to the proximal femur must exceed its strength ( ie . Bone strength at the hip must be insufficient)

17. ASSOCIATED INJURIES/DISEASE STATES Low energy falls – distal radius, proximal humerus fractures and minor head injuries High energy hip fractures – ipsilateral extremity trauma, head injury and pelvic fractures Syncopal episodes – gives an idea of the CVS and neurological status Primary neoplastic and metastatic disease – preceding hip discomfort and subsequent fall

18. HISTORY AND PHYSICAL EXAMINATION History of pain and inability to ambulate after a fall or other injury Pain is localized to the proximal thigh; exacerbated by passive attempts at hip flexion or rotation Drug use – contributing factor Nursing home and institutionalized patients – potential neglect and abuse – previous fractures, injuries in different states of repair and decubiti (bedsores/skin peels)

19. EXAMINATION Shortening of the extremity and deformity of rotation in resting position compared with the other extremity Pain with motion/ Crepitance testing – NOT elicited unless there are no obvious physical signs of deformity and radiographic studies are negative for an obvious fracture. Pain with axial load on the hip – high correlation with occult fracture

20. EXAMINATION Auscultation Lippmann test – sensitive for detection of occult fractures of the proximal femur or pelvis Bell of the stethoscope on symphysis pubis and tapping on the patella of both extremities – variation in sound conduction determines discontinuity Decreased tone or pitch - fracture

21. WORKUP Pre-surgery workup – Complete Blood Count, HIV, HBsAG , HCV, S. Creatinine , BUN Sugars, Blood grouping & cross matching, Chest XRAY, ECG Low energy fractures – Serum calcium, phosphate, alkaline phosphatase , Vitamin D, TSH, PTH, Serum Protein Electrophoresis

22. WHAT ELSE TO LOOK FOR WHILE DOING A WORKUP? Previous DVT/PE Anticoagulant medications Immune deficiency disorders Malabsorption disease Angina CVAs Active infection – pulmonary or genitourinary (risk of sepsis) Protein-calorie malnutrition and Vitamin D deficiency

23. IMAGING STUDIES - XRAYS Pelvis with both hips – AP, xray of the affected hip – AP and cross-table lateral Traction films (with internal rotation) – helpful in communited and high-energy fractures and in determining implant selection Subtrochanteric extension – Femur AP and lateral

24. OTHER IMAGING STUDIES Magnetic Resonance Imaging (MRI) – currently the imaging study of choice in delineating non-displaced or occult fractures that may not be apparent on plain radiographs – Preferred over CT due to higher sensitivity and specificity for a more rapid decision process

25. OTHER IMAGING STUDIES Bone scans or CT – reserved for those who have contradictions to MRI. Technetium bone scans Technetium bone scan – when a hip fracture is suspected but not apparent to standard radiographs – requires 2-3 days to become positive

26. OTHER IMAGING STUDIES CT – useful in establishing the diagnosis in nonobvious fractures and atypical fractures in high-energy trauma patients. Fluoroscopic C-ARM control

27. DIAGNOSIS AND CLASSIFICATION Increased surgical complexity and recovery are associated with UNSTABLE FRACTURE PATTERNS: - Posteromedial large separate fragmentation - Basicervical patterns - Reverse obliquity patterns - Displaced greater trochanteric (lateral wall fractures) - Failure to reduce the fracture before internal fixation

28. CLASSIFICATION SYSTEMS No single classification system that has achieved reliable reproductive validity 1822 – Astley Cooper (London) described the first (pre-radiographic) classification of hip fractures - Intracapsular (main complication – non-union) - Extracapsular (main complication – coxa vara )

29. BOYD AND GRIFFIN CLASSIFICATION Stable (Two part) Unstable with posteromedial communition Subtrochanteric extension into lateral shaft, extension of the fracture distally at or just below the lesser trochanter (the term Reverse Obliquity was coined by Wright) Subtrochanteric with intertrochanteric extension with the fracture lying in atleast two planes

30. BOYD AND GRIFFIN CLASSIFICATION Type iii and iv are the most difficult types to manage Account for one third of the trochanteric fractures

31. EVAN’S CLASSIFICATION Evans (Birmingham) in 1949 reported on a post-treatment classification with 5 types described He compared non-operative treatment with fixed angle device surgical treatment and found that in 72% fractures could be fixed in a stable configuration, 28% unstable (14% as a result of fracture communition and 14% in which he felt that reduction was never achieved)

32. EVAN’S CLASSIFICATION In 1979 and 1980 Kyle et. al. and Jensen et. al. revised the Evans Classification incorporating the lateral radiographic position of the posteromedial fracture component and its relative stability with sliding fixation systems. They showed an increasing rate of deformity and collapse with increasing instability classification.

33. WHY WAS EVAN’S CLASSIFICATION IMPORTANT? Because it distinguished stable from unstable fractures and helped define the characteristics of a stable reduction. - Stable fracture patterns – posteromedial cortex remains intact OR has minimal communition - Unstable fracture patterns – characterised by disruption or impaction of the posteromedial cortex- can be converted into stable if medial cortical opposition is maintained. - Reverse Oblique – Inherently unstable due to the tendency for medial displacement of the femoral shaft

34. OTA/AO CLASSIFICATION The most quoted in recent scientific articles – a derivative of the Muller classification Has been very useful in evaluating the results of treatment of intertrochanteric fracture and allowing comparisons among reports in literature

35. OTA/AO CLASSIFICATION Group 1 fractures (31A1) – Pertrochanteric simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex; the lateral cortex of the greater trochanter remains intact. A1.1 – Along intertrochanteric line A 1.2 – Through greater trochanter A 1.3 – Below lesser trochanter

36. OTA/AO CLASSIFICATION Group 2 fractures (31A2) – Pertrochanteric multifragmentary - comminuted with a postero -medial fragment; the lateral cortex of the greater trochanter however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment. A2.1 – With one intermediate fragment A2.2 – With several intermediate fragments A2.3 – Extending more than 1cm below lesser trochanter .

37. OTA/AO CLASSIFICATION Group 3 fractures (31A3) – TRUE INTERTROCHANTERIC - are those in which the fracture line extends across both the medial and lateral cortices; this group also includes the reverse obliquity pattern. A3.1 – Simple oblique A3.2 – Simple transverse A3.3 - Multifragmentary

38. OTA/AO CLASSIFICATION

39. OTA/AO CLASSIFICATION

40. UNUSUAL FRACTURE PATTERNS – BASICERVICAL FRACTURES Located proximal to or along the intertrochanteric line. Although anatomically femoral neck fractures they are usually extracapsular and behave like intertrochanteric fractures. At greater risk for osteonecrosis when compared to more distal intertrochanteric fractures Lack the cancellous interdigitation seen with fractures in the intertrochanteric region and are more likely to sustain rotation of the femoral head

41. UNUSUAL FRACTURE PATTERNS – REVERSE OBLIQUITY Oblique fracture line extending from the medial cortex proximally to the lateral cortex distally Tendency to medial displacement ddue to the pull of the adductor muscles Should be treated as subtrochanteric fractures

42. TREATMENT OPTIONS – NON-OPERATIVE Prolonged bedrest in traction until fracture healing occurred (usually 10 to 12 weeks), followed by a lengthy program of ambulation training. Can be done for: 1.An elderly person whose medical condition carries an excessively high risk of mortality from anaesthesia and surgery. 2.Nonambulatory patient who has minimal discomfort following fracture

43. TREATMENT OPTIONS – NON OPERATIVE Buck’s traction or extension Russell skeletal traction Balanced traction in Thomas splint Plaster spica immobilization Derotation boot

44. COMPLICATIONS OF NON-OPERATIVE TREATMENT Decubiti , UTI, joint contractures, pneumonia, and thromboembolic complications, resulting in a high mortality rate. In addition, fracture healing is generally accompanied by varus deformity and shortening because of the inability of traction to effectively counteract the deforming muscular forces.

45. OPERATIVE TREATMENT As soon as the general condition of this patient is under control, internal fixation should be carried out. The goal of surgical treatment is strong, stable fixation of the fractured fragments

46. OPERATIVE TREATMENT – FACTORS THAT DETERMINE THE STRENGTH OF THE FRACTURE FRAGMENT-IMPLANT ASSEMBLY Bone quality Fracture geometry Reduction Implant design Implant placement

47. REDUCTION Closed reduction Open reduction

48. REDUCTION – CLOSED REDUCTION Longitudinal traction given in slightly abducted position Depending on the fracture type, the amount of rotation is decided If proximal fragment – head and neck alone – does not have muscle attachment, remains in neutral EXCEPT in case of slightly displaced fracture

49. REDUCTION – CLOSED REDUCTION Head and major part of GT form the proximal fragment – the external rotator muscles inserted into GT tend to rotate the proximal fragment laterally; hence we need to reduce with distal fragment placed in some degrees of external rotation

50. REDUCTION – CLOSED REDUCTION In case of communited fractures, the posterior sag of the distal fragment may be corrected by lifting up with a HIP SKID under the fracture by an assistance or with the use of a crutch under the proximal thigh. Post-op xrays – to confirm reduction with spl . Attention paid to cortical contact medially and posteriorly

51. REDUCTION – OPEN REDUCTION Failed closed reduction Large spike on proximal fragment with lesser trochanter intact Reverse oblique fracture If a gap exists medially or posteriorly

52. OPEN REDUCTION TECHNIQUES Anatomical Stable Reduction – applying a bone holding forceps across the fracture in an anteroposterior plane while adjusting the traction and rotation if the fracture is not severely comminuted . Once achieved – compression hip screw or other device can be used to secure the reduction

53. OPEN REDUCTION TECHNIQUES Non-anatomical stable reduction - in case of severely comminuted fracture where anatomical reduction is difficult or impossible. Done to convert it into stable fracture

54. NON-ANATOMICAL STABLE REDUCTION TECHNIQUES Medial displacement osteotomy a.k.a Dimon – Hughston osteotomy a. Transverse osteotomy of the proximal femoral shaft at the level of LT b. Osteotomy , if necessary, and proximal displacement of the greater trochanter and attached abductors c. Medial Displacement of the femoral shaft d. Impaction of the proximal fragment into the medullary canal of the femoral shaft

55. NON ANATOMICAL STABLE REDUCTION TECHNIQUES Disadvantages of the technique include – limb shortening, level of function and proximal migration of the GT significantly comprises abductor function increasing the stress on the implant and impairing patient’s ability to walk.

56. NON ANATOMICAL STABLE REDUCTION TECHNIQUES Valgus Osteotomy (Sarmiento Osteotomy ) which involves a. An oblique osteotomy of the proximal femoral shaft extending from the base of GT to medial position 1cm distal to the apex of the fractures b. Implant placement into the proximal fragment 90 deg to the fracture surface c. Reduction and impaction of the osteotomy surface

57. NON ANATOMICAL STABLE REDUCTION TECHNIQUES Pitfalls associated with this technique a. Excessive valgus osteotomy which increase the force required by abductors to stabilize pelvis – increased joint reaction forces b. Excessive limb shortening c. External rotation deformity

58. NON ANATOMICAL STABLE REDUCTION TECHNIQUES Lateral displacement a.k.a Wayne County Osteotomy which involves lateral displacement of the femoral shaft to create a medial cortical overlap. Applied to those relatively unstable fractures with a posteromedial fragment

59. OPERATIVE TREATMENT APPROACHES – LATERAL APPROACH TO THE FEMUR Most standard approach for plate fixation Fracture table with leg and foot secured after a closed reduction Incision based on the length of the proposed plate-shaft component, centered around the lesser trochanter (commonly 5-10cm length) Incision of iliotibial band -> Vastus lateralis at its attachment posteriorly near the linea aspera and reflection of the vastus anteriorly to expose the lateral femoral shaft

60. OPERATIVE TREATMENT APPROACHES – INTRAMEDULLARY APPROACH Intersection of a line from the anterior superior iliac spine directed posteriorly and a line parallel to the long axis of femur Overlay a 3.2 guidewire over the skin and confirm alignment with proximal femur under c-arm guidance. Skin proximal to GT is incised (3-5cm), fascia incised but the gluteus medius fibres are NOT dissected. A targetting guide and a trocar system protects the gluteus medius .

61. OPERATIVE TREATMENT APPROACHES – WATSON JONES APPROACH It is an anterolateral approach – proximal expansion of the straight lateral approach Proximally: Interval between the tensor fascia latae and gluteus medius is exposed in a distal to proximal fashion. The anterior border of vastus lateralis to reach the anterior trochanteric ridge and the hip capsule Schanz pins can be drilled into the proximal femur as an aide in retraction for better visualization and may be used for manipulation of the shaft.

62. OPERATIVE TREATMENT APPROACHES – WATSON JONES APPROACH Main vascular obstacle is the ascending branch of the lateral circumflex femoral artery which should be isolated and ligated . The superior gluteal nerve to the tensor fascia latae is sacrified – however it is not of much clinical significance

63. OPERATIVE METHODS Plate Constructs Cephalomedullary nailing External Fixation Arthroplasty

64. PLATE CONSTRUCTS Impaction class – Impacted nail-type plate devices eg . Blade plate and fixed angle nail plate devices Dynamic compression class – large single sliding screw or nail, femoral head components with side plate attachments eg . Sliding hip screws Linear compression class – Multiple head fixation components controlling rotation and translation but allowing linear compression eg . Gotfried PCCP and the InterTAN CHS Hybrid Locking Class – Multiple fixation components with compression initially for fracture reduction followed by locking screws which prevent further axial compression eg . Proximal Femoral Locking Plates – Synthes , Paoli, PA and Smith-Nephew

65. PLATE CONSTRUCTS – FIXED ANGLE PLATING More commonly used for corrective osteotomies nowadays rather than as a primary treatment of hip fractures Eg . Jewett Nail, Holt Nail, SP Nail and Plate, Thornton Nail, AO blade plate. Consist of a triflanged nail fixed to a plate at an angle of 130 to 150 degrees.

66. SMITH PETERSON NAIL WITH MCLAUGHLIN PLATE

67. JEWETT NAIL

68. FIXED ANGLE PLATING - DISADVANTAGES Does not allow for fracture impaction According to Chinoy et. al. (1999) – when compared with the sliding hip screw series, there was an increased risk of cutout , non-union, implant breakage and reoperation, in addition to higher mortality owing to the residual pain in the hip and impaired mobility

69. PLATE CONSTRUCTS – DYNAMIC COMPRESSION PLATING From the 1980s to 2000 – Sliding compression hip screws became the gold standard for hip fracture fixation. Historically the most commonly used device for both stable and unstable fracture patterns. Available in plate angles from 130deg to 150deg. The 135 degree plate is most commonly utilized; this angle is easier to insert in the desired central position of the femoral head and neck than higher angle devices and creates less of a stress riser in the subtrochanteric region.

70. SLIDING HIP SCREW

71. PLATE CONSTRUCTS – DYNAMIC COMPRESSION PLATING The most important technical aspects of screw insertion are: 1. Placement within 1cm of subchondral bone to provide secure fixation 2. Central position in the femoral head (Tip-apex distance)

72. TIP-APEX DISTANCE Sum of distances from the tip of the lag screw to the apex of the femoral head on both the anteroposterior and lateral radiographic views. The sum should be <25mm to minimize the risk of lag screw cutout

73. PLATE CONSTRUCTS – DYNAMIC COMPRESSION PLATING Variations on the sliding hip screw's basic design include the Richards’ plate, Calandruccio plate, V ariable angle hip screw (VHS) , Talon compression hip screw, greater trochanteric stabilizing plates, the Medoff sliding plate, and the percutaneous compression plate (PCCP).

74. PLATE CONSTRUCTS – MEDOFF PLATE Designed by Medpac , Culver City, California US Uses a biaxial sliding hip screw Has a standard lag screw/barrel component for compression along the femoral neck. In place of the standard femoral side plate – coupled pair of sliding components – enable fracture impaction parallel to longitudinal axis of femur

75. PLATE CONSTRUCTS – MEDOFF PLATE If a locking set screw is applied within the plate, then the plate can only slide axially on the femoral shaft – uniaxial dynamization . If a surgeon applies the implant without placement of the locking set screw, sliding may occur along both the femoral neck and femoral shaft (biaxial dynamization ) which is suggested.

76. PLATE CONSTRUCTS – TALON COMPRESSION HIP SCREW The Talon compression hip screw system incorporates a series of four prongs that protrude from the base of the threads of the lag screw The prongs are designed to engage the cortical bone at the inferior aspect of the femoral neck

77. PLATE CONSTRUCTS – TALON COMPRESSION HIP SCREW This construct theoretically: Increases the pull out strength of the lag screw from the femoral head and neck fragment Provides better rotational stability of the femoral head around the lag screw.

78. PLATE CONSTRUCTS – TALON COMPRESSION HIP SCREW A laboratory study comparing use of the Talon hip screw system reported that use of the prongs increased the peak compressive forces generated by Talon device only when the lag screw was inserted in the inferior aspect of the femoral neck and head

79. PLATE CONSTRUCTS – TROCHANTERIC STABILIZING PLATE The trochanteric stabilizing plate and the lateral buttress plate are modular components that buttress the greater trochanter . These plates are placed over a four-hole sideplate and are used to prevent excessive slide (and resulting deformity) in unstable fracture patterns. These devices prevent telescoping of the lag screw within the plate barrel when the proximal head and neck fragment abuts the lateral buttress plate.

80. PLATE CONSTRUCTS – LINEAR COMPRESSION CLASS A.K.A Rotationally Stable Plating – adds enhanced rotational stability with multiple screw fixation in the femoral head Examples – Gotfried PCCP and InterTAN CHS

81. PLATE CONSTRUCTS – HYBRID LOCKING PLATES These devices offer maximal stability with initial compression and fixed angle stability from locking screws Early failure rate with original plate designs and three screw limitation Newer devices with enhanced fixation – IT fractures with subtrochanteric extension

82. HYBRID LOCKING PLATE – SMITH AND NEPHEW

83. CEPHALOMEDULLARY DEVICES Inserted through the piriformis fossa OR lateral greater trochanter OR medial greater trochanter Femoral head component – screw/blade interlocked with nail component Dissatisfaction with use of a sliding hip screw in unstable fracture patterns led to the development of intramedullary hip screw devices.

84. CEPHALOMEDULLARY DEVICES Russell classified cephalomedullary nails into four classes: Impaction/Y nail class – originated with Kuntscher nail and current TFN nail ( Synthes ) Dynamic compression or Gamma Class – large head nail component with a single large lag screw

85. CEPHALOMEDULLARY DEVICES Reconstruction class – Russell and Taylor (Smith and Nephew) Integrated class – nail design cross section with the stability of an arthroplasty hip stem and integrated two-screw construct with linear compression at the fracture site (InterTAN) Other IM devices – Ender’s nail, single rigid condylocephalic rod of Harris

86. CEPHALOMEDULLARY NAILS - ADVANTAGES Because of its location, theoretically provides more efficient load transfer than does a sliding hip screw. The shorter lever arm of the intramedullary device can be expected to decrease tensile strain on the implant, thereby decreasing the risk of implant failure. Because the intramedullary fixation device incorporates a sliding hip screw, the advantage of controlled fracture impaction is maintained Shorter operative time and less soft-tissue dissection than a sliding hip screw .

87. PROXIMAL FEMORAL NAIL The PFN nail has been shown to prevent the fractures of the femoral shaft by having a smaller distal shaft diameter which reduces stress concentration at the tip. Due to its position close to the weight-bearing axis the stress generated on the intramedullary implants is negligible.

88. PROXIMAL FEMORAL NAIL PFN implant also acts as a buttress in preventing the medialisation of the shaft. The entry portal of the PFN through the trochanter limits the surgical insult to the tendinous hip abductor musculature only , unlike those nails which require entry through the piriformis fossa .

89. EXTERNAL FIXATION As reported by Moroni et. al. May be indicated in osteoporotic hip fractures in elderly patients who may be deemed at high risk for conventional open reduction and internal fixation Also for those who cannot receive blood transfusions because of personal conviction or religion ( eg . Jehovah’s witnesses)

90. EXTERNAL FIXATION Use was unsuccessful because of high rate of pin-tract infection, subsequent pin loosing, varus collapse, instability and failure Latest – new fixation designs and the addition of hydroxyapatite coated pin technology

91. ARTHROPLASTY Neoplastic fractures, severe osteoporotic disease, renal dialysis patients and pre-existing arthritis under consideration for hip replacement before the fracture occured Hemiarthroplasty reported to have a lower dislocation rate when compared to total hip arthroplasty

92. ARTHROPLASTY Better salvage operation for failed internal fixation rather than a first-line choice in geriatric patient. No level-one evidence to show any difference between compression hip screw and arthroplasty except for a higher blood transfusion rate with arthroplasty

93. ARTHROPLASTY-DISADVANTAGES Morbidity associated with a more extensive operative procedure Internal fixation problems with greater trochanteric reattachment Risk of postoperative prosthetic dislocation

94. SPECIAL CONSIDERATIONS SHS – GT displacement should be fixed utilizing tension band techniques or a trochanteric stabilizing plate and screw construct Basicervical fractures treated with an SHS or IM nail may require a supplemental antirotation screw or pin during implant insertion.

95. SPECIAL CONSIDERATIONS Reverse obliquity fractures are best treated as subtrochanteric fractures with either a 95 degree fixed angle implant or an intramedullary device Ipsilateral fracture of the femoral shaft, although more common in association with femoral neck fractures, should be ruled out in cases of high energy trauma.

96. POST-OPERATIVE CARE AP and lateral radiographs while the patient is still in the surgical area Patient mobilized to chair upright position the day after the operative procedure Ambulation – under supervision with weight bearing as tolerated with a walker or crutches – emphasis on heel-strike and upright balance exercises

97. POST – OPERATIVE CARE Multiple trauma/co-morbidities – difficulty in early ambulation but must be done as soon as possible to minimize secondary complications Weight bearing – for optimal recovery and to reduce the fear of falling/lack of independence Good pain control

98. POST-OPERATIVE CARE Protein and caloric nutrition, osteoporotic therapy including Vitamin D supplementation Hip abductor exercises bilaterally in conjunction with proper balance and gait training Patient to be counseled to report any swelling or respiratory distress – risk of thromboembolic disease

99. POST – OPERATIVE CARE ON DISCHARGE – fall prevention education and safe home checks to be explained to the family or social support group Re-evaluation of the patient in the OPD with X-Rays at 2 weeks and then monthly thereafter until fracture healing is documented OR patient has maximum ambulation (usually 6 months after injury)

100. COMPLICATIONS Loss of fixation Nonunion Malrotation deformity Osteonecrosis Medical, psychosocial, thromboembolic

101. COMPLICATIONS – LOSS OF FIXATION Commonly characterized by varus collapse of the proximal fragment with cut-out of the lag screw from the femoral head Occurs within 3 months of surgery due to eccentric placement of lag screw within femoral head, improper reaming, unstable reduction, excessive fracture collapse which exceeds the sliding capacity of the device

102. COMPLICATIONS – LOSS OF FIXATION Inadequate screw-barrel engagement which prevents sliding and severe osteopenia Management – acceptance of the deformity, revision ORIF with PMMA or conversion to prosthetic replacement

103. COMPLICATIONS – NON-UNION Uncommon. May follow internal fixation more often than closed treatment Should be suspected with patients with persistent hip pain that have radiographs revealing a persistent radiolucency at the fracture site 4-7 months after fracture fixation

104. COMPLICATIONS NON-UNION Managed by open reduction, renailing and bone grafting

105. COMPLICATIONS – MALROTATION DEFORMITY Internal rotation of the distal fragment at surgery Unstable fracture patterns – the proximal and distal fragments may move independently – such cases the distal fragment should be placed in neutral/slight external rotation during plate fixation

106. COMPLICATIONS – MALROTATION DEFORMITY Severe malrotation which interferes with ambulation – revision surgery with plate removal and rotational osteotomy of the femoral shaft should be considered. Z-Effect – seen most commonly with dual screw CM nails – most proximal screw penetrates the hip joint and distal screw backs out of the femoral head

107. COMPLICATIONS – OSTEONECROSIS OF THE FEMORAL HEAD Rare Lag screw-side plate dissociation Occurs due to traumatic laceration of the superficial femoral artery by a displaced lesser trochanter fragment

108. COMPLICATIONS - MEDICAL Cardiopulmonary complications most frequent Other complications – GI bleeding, venous thromboembolism , transient ischemic attacks or stroke. Renal complications rare.

109. COMPLICATIONS - MEDICAL Thromboembolic compications Options – pentasaccharides , LMW heparin, adjusted dose warfarin , mechanical compression and aspirin. Prophylaxis recommended for 4-6 weeks postoperatively because of reports of late pulmonary embolism and DVT

110. COMPLICATIONS - MEDICAL Infection – seen in 1-2% postoperative patients – can be minimized by preoperative antibiotics – cephalosporins Vigilance with a high index of suspicion for any signs of wound inflammation or drainage Oral antibiotics for 7-10 days if the infection is superficial

111. COMPLICATIONS - PSYCHOSOCIAL Frequent concerns regarding imminent mortality especially if they’ve had loved ones who have died from hip fractures in the past Questions regarding their ability to walk again and regain the pre-fracture level of independence

112. COMPLICATIONS - PSYCHOSOCIAL Fear of falling - best addressed by the patient’s ability to trust in the injured extremities’ support Patients with improved mobility early in the post-operative period develop better functional abilities at the 3 and 6 month periods.

113. GREATER TROCHANTERIC FRACTURES Rare – typically occur in older patients as a result of an eccentric muscle contraction or less commonly a direct blow Treatment – usually non-operative. Operative considered in younger, active patients with a widely displaced greater trochanter

114. GREATER TROCHANTERIC FRACTURES ORIF with tension band wiring of the displaced fragment and the attached abductor muscles or plate and screw fixation with a “hook plate” are the preferred techniques

115. LESSER TROCHANTERIC FRACTURES Most common in adolescence, typically secondary to forceful iliopsoas contracture In elderly, isolated lesser trochanter fractures have been recognised as pathognomonic for pathologic lesions of the proximal femur Treatment – identifying the pathologic lesion and treating accordingly. If no evidence of pathologic lesion – symptomatic treatment to gain ROM and ambulation.

116. HIP FRACTURES IN CHILDREN Classification proposed by Delbet and popularized by Colonna Type – 1 : Transepiphyseal separations with or without dislocation of femoral head from the acetabulum Type – 2 : Transcervical fractures, displaced and non-displaced

117. HIP FRACTURES IN CHILDREN Type – 3 : Cervicotrochanteric fractures, displaced and non-displaced Type – 4 : Intertrochanteric fractures Rapid union almost always occurs in 6-8 weeks. Skeletal traction followed by abduction spica cast worn for 6-12 weeks

118. HIP FRACTURES IN CHILDREN When fracture cannot be reduced with traction, closed reduction may be necessary followed by abduction spica cast. Rarely, internal fixation is warranted depending on the age of the child

119. COMPLICATIONS OF HIP FRACTURES IN CHILDREN Avascular necrosis Coxa vara Non-union Premature epiphyseal closure

120. THANK YOU!