Neck of Femur Fractures in malaysia.pptx

Neck of Femur Fractures in malaysia

1. Neck of Femur Fractures AMT Team CME 16.2.24

2. Overview of Presentation Epidemiology & risk factors Presentation & diagnosis Classifications ED & Ward Management Surgical Management of NOF Fractures Guidelines for reference

3. Epidemiology

4. How does Malaysia compare? Latest data was collected in 1996-97 by 56 public and private hospitals 90 per 100,000 population among those > 50years of age (Ong et. al - MOJ 2020) 5800 hip fractures occur annually in Malaysia Cost of treatment is over USD35 million (Hong et. al - J Orth Trauma & Rehab 2023)

5. Risk factors for fragility NOF # MAJOR OSTEOPOROSIS Osteomalacia Frequent falls Others: Race (White > Black) Medications Increasing age (75 yrs) Gender (post menopausal women) Environmental factors Previous Hx of osteoporosis or fragility fractures Poor nutrition and lifestyle (smoking & alcohol)

6. Related anatomy and clinical relevance Blood supply: Terminal branch of MFC artery Predominant blood supply to weight bearing dome of femoral head The LFCA supplies portions of the anterior and inferior femoral head AFTER #, blood supply depends on retinacular vessels

7. NOF anatomy Physeal close at age 16 Neck shaft angle (130 +/- 7 degrees) Anteversion (10 +/- 7 degrees) Calcar femorale (posteromedial side has dense plate of bone)

8. Classifications of NOF # General classification: Intracapsular Extracapsular There are 3 notable classifications: Garden’s (1961) Pauwel’s AO Classification Intracapsular VS extracapsular hip #

9. Garden’s Classification (I & II non displaced vs III & IV displaced) Degree of displacement Relates to risk of vascular disruption Most commonly applied to geriatric/ insufficiency fractures

10. Pauwel’s Classification (based on angle of the fracture) Fracture orientation Relates to biomechanical stability More vertical fracture = more shear force More commonly used in younger patients or high energy NOF #

11. AO classification (more comprehensive & used in research)

12. Typical presentation History of trivial trauma/ fall causing hip pain and reduced ability to weight bear In displaced NOF # presents with deformed limb (shortened + externally rotated) Impacted & non-displaced presents with moderate pain in the groin. Still might be able to SLR with some discomfort. Only mild pain with passive ROM during physical exam of the hip. Trochanteric # - might only present with moderate deformity but unable to SLR Subtrochanteric # - deformed. Can cause bleeding.

13. Making the diagnosis Plain radiographs (x-ray AP and Lateral hip joint) - not always diagnostic Need full length femur when pathological # suspected MRI (gold standard) when x-rays are negative (NICE 2017) CT scan in subtrochanteric fractures (when MRI not available in occult # Repeated x-rays after 24-48 hours has poor sensitivity Radioisotope bone scan can be considered if difficulties with other methods

14. Management of NOF # MEDICAL Management PRE-OPERATIVELY Good history Thorough examination POST-OPERATIVELY Surgical Mx

15. Preoperative assessment Mechanism of injury Pre-injury status Neurovascular status Pain score & core body temperature Fluid balance & nutrition status History of incontinence and mental state Previous mobility & function Social circumstances Drug & medical history

16. Management in ETD Pain relief (oral, IV, IM or nerve block) Pressure sores prophylaxis (good nursing care, monitoring of skin condition, keep skin dry, special mattresses) Prevent hypothermia Blood tests (FBC, electrolytes, GSH, coag screening), ECG CXR (suspect cardiac OR respiratory compromise) Correct fluid & electrolyte imbalance Correction of anticoagulation

17. Post-operative medical management MDT approach: early liaison + orthogeriatric team (in 72H of admission) Falls prevention and bone health assessment & improvement Early physiotherapy Daily R/V by the surgical, orthogeriatric, nursing team (nutrition status, return to bodily function to normal, mental status, routine observations, wound healing, signs & symptoms of complications) Discharge planning from D1 of admission (step down care home, nursing home, post discharge rehabilitation)

18. Assessment of bone health. How to go about it? Involves MDT Fragility fracture means NEED for assessment of bone health Online tools (FRAX - Fracture Risk Assessment Tool - Uni of Sheffield) DEXA scan for osteoporosis Falls prevention clinics Start Tx of Osteoporosis according to national guidelines

19. Surgical Management ASPECTS of Discussion: Timing of surgery Tx of Intracapsular NOF # (Displaced vs Nondisplaced ) Tx of extracapsular NOF # Tx of subtrochanteric NOF # Complications of surgery

20. Timing of surgery As soon as fit This is aimed to achieve early W/B & quick return to normal function Retrospective cohort studies SHOWS earlier operation LEADS to better mortality & morbidity, decreased hospital stay, return to mobility & likelihood to return to residence Delays in surgery leaves patient in pain, prolonged immobilization, HAI risk etc NICE guidelines (2019) recommends surgery on the day of, or the day after admission AAOS (MODERATE EVIDENCE) = Surgery performed within 48H - 72H Delay in surgery >48H increases 1-yr mortality risk (0.34 - 0.74) NICE guidelines

21. INTRACAPSULAR NOF (UNDISPLACED #) CONSERVATIVE Mx Frail patients with limited life expectancy When patients present late with little or no symptoms + non-displaced radiologically SURGICAL Tx Assess if the fracture is truly undisplaced 1st DHS or Cannulated screws NICE 2017 guidelines did not discuss regarding operative options due to limited quality and quantity of evidence

22. Displaced intracapsular NOF # No role for conservative Tx (high risk of AVN & non-union) Internal fixation has up to 40% risk of implant failure and reoperation rates due to AVN / non-union Hemiarthroplasty VS THR HEMIARTHROPLASTY: Low demand patients with advanced physiological OR chronological age (>80) OR using walking with aids such as frame/walking stick In patients with HIGH RISK OF HIP DISLOCATION (Parkinson’s disease, advanced dementia OR prior stroke) NICE guidelines (Lower dislocation in hemi BUT THR has better functional status at 1yr and 5yrs) Cemented vs uncemented? Bipolar vs monopolar? Dual mobility vs conventional?

23. Algorithm of treatment for displaced intracapsular NOF # Antrapur et al. Clinical Interventions in Aging 2011

24. Total Hip or Hemiarthroplasty?

25. Extracapsular NOF # Fixed angle plates are now out of favour DHS Vs IM Nailing Contraindicated for using DHS in reverse obliquity # (high risk of screw cut out and implant failure) Nail traditionally used for # with loss of lateral wall, comminuted IT #, reverse oblique, + when fracture extends to subtrochanteric area

26. Subtrochanteric # IM nailing is preferred Advised to have an anatomical reduction before reaming & insertion of nail Be aware of varus deformity due to proximal fragment drifting to flexion, abduction and external rotation due to iliopsoas pull Positioning blocking wires to push guide wire to centre of medullary canal, or the open reduction techniques using clamps or temporary small plates

27. Complications of surgery (EARLY or LATE / Specific OR General) AVN (10% undisplaced, 30-45% displaced) Ballas et.al 2023 J Nuc Med Tech Delayed or non-union Metal work problems (implant breakage, prominence, cut out) General complications - such as infection, thromboembolism, wound problems, pain, stiffness, limb length discrepancy leading to limping, sciatic nerve injury, bleeding. Hip dislocation Periprosthetic fracture

28. Displaced intracapsular # NOF in Young Adults Unique population (significant force to a strong bone - usually will present with significant concomitant injuries) <65 yrs chronologically, physiologically young means anyone with strong bones and requires significant trauma to cause the injury Timing of surgery: AAOS recommends as soon as stable with aim to achieve anatomical reduction & stable internal fixation Quality of reduction is most important factor in determining good outcomes Closed reduction (Leadbetter maneuver) vs open reduction No need for capsulotomy - no proven benefit (Maruenda Barrios, Clin Orth Rel Res 1997) Cannulated screws / DHS

29. Pathological NOF fracture - Metastases High index of suspicion in elderly patients with PRIOR pain before the minor trauma/ no trauma Look for signs in x-rays (eg. lytic lesion). Need to do full length plain radiograph (Femur AP/ Lat) Surgery can wait while investigations are done (workup primary or secondary lesion) Proper history for other red flag signs Examine for possible primary Ca IX: MRI whole femur, CT TAP, Blood Ix (add myeloma screen, bone profile, relevant Ca markers) MDT approach Surgical Mx: Implant has to outlive patient, assume the fracture will never heal Role of prophylactic nailing based on Mirel’s score

30. Pathological fracture: Atypical fracture Due to impaired osteoclastic activity , decreasing bone turnover Causes: Prolong use of bisphosphonates , non-Hodgkin’s lymphoma, hypophosphatasia, osteopetrosis, vit D deficiency and RA Nailing MRI can show impending fracture Can consider prophylactic nailing on contralateral femur Prolonged healing common Bisphosphonate holiday

31. Atypical fracture diagnostic criteria MAJOR conditions Absence of any trauma Femur fracture in any diaphyseal location (from below lesser trochanter to proximal to supracondylar region) Transverse or short oblique fracture Non- comminuted fracture Fractures involve only lateral cortex in incomplete fracture cases 4 or more = diagnostic Minor Conditions Periosteal thickening in lateral cortex of bone Indicative symptoms Comorbidities in association with usage of medications that increase risk of fractures Association with bilateral fracture and/ or symptoms

32. Ipsilateral shaft and NOF fracture 1 - 9 % patients with femoral shaft also have NOF # MRI best (shows bone and also soft tissue injuries) but expensive and impractical Thin cut CT has 12% false negative rate During fixation surgery - priority to NOF fracture (worse complications) Single device (IM nail) Separate devices (Cannulated screws/ DHS) with retrograde femoral nailing are more favoured (Mohan et. al 2019 - Orth Rev) Easier to reduce both fractures anatomically using separate implantes

33. Stress Fracture NOF New military recruits or recreational athletes Due to repeated submaximal stress Young females with Female athlete triad (anorexia, amenorrhea & osteoporosis) Tension type (superior aspect of NOF) Compression type (inferior aspect of NOF) Gradual onset of pain in the groin/hip which improves with rest and aggravates with W/B or high impact activities

34. Guidelines for reference NICE Guidelines for Hip Fracture Management (UK) 2017 BOAST Guidelines (2007) AAOS CPG (2021) Management of hip fractures in older adults

35. References National Clinical Guideline Centre, (2011) [The Management of Hip Fracture in Adults]. London: National Clinical Guideline Centre. Available from: www.ncgc.ac.uk British Orthopaedic Association Standard for Trauma (BOAST) Patients sustaining a fragility hip fracture (2012) American Academy of Orthopaedic Surgeons Management of Hip Fractures in Older Adults EvidenceBased Clinical Practice Guideline. https://www.aaos.org/hipfxcpg Published 12/03/2021 Rha JD, Kim YH, Yoon SI, Park TS, Lee MH. Factors affecting sliding of the lag screw in intertrochanteric fractures. Int Orthop. 1993 Nov;17(5):320-4. Ballas ER, Nguyen VT, Wolin EA. Femoral Neck Fracture with Avascular Necrosis. J Nucl Med Technol. 2023 Mar;51(1):78-79 Harewood S, Mencia MM, Harnarayan P. The rendezvous technique for the treatment of ipsilateral femoral neck and shaft fractures: A case series. Trauma Case Rep. 2020 Jul 28;29:100346. doi: 10.1016/j.tcr.2020.100346. Erratum in: Trauma Case Rep. 2023 Mar 01;45:100808. PMID: 32793794; PMCID: PMC7413999. Rapp K, Büchele G, Dreinhöfer K, Bücking B, Becker C, Benzinger P. Epidemiology of hip fractures : Systematic literature review of German data and an overview of the international literature. Z Gerontol Geriatr. 2019 Feb;52(1):10-16. Seeley MA, Georgiadis AG, Sankar WN. Hip Vascularity: A Review of the Anatomy and Clinical Implications. J Am Acad Orthop Surg. 2016 Aug;24(8):515-26. Zhang K, Zhang S, Yang J, Dong W, Wang S, Cheng Y, Al-Qwbani M, Wang Q, Yu B. Proximal femoral nail vs. dynamic hip screw in treatment of intertrochanteric fractures: a meta-analysis. Med Sci Monit. 2014 Sep 12;20:1628-33. Viberg B, Barat S, Rotwitt L, Gundtoft PH., DFDB collaborators. Reoperation for sliding hip screws vs cannulated cancellous screws in femoral neck fractures: A study from the Danish Fracture Database Collaborators. Injury. 2022 Nov;53(11):3805-3809.