Fractures of the Femoral Neck and Intertrochanteric Fracturs

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Fractures of the Femoral Neck and Intertrochanteric Fracturs Powered By Docstoc
					 Fractures of the Femoral Neck
and Intertrochanteric Fractures


  Knut Strömsöe, MD PhD, Orthopaedic
  Department, Aker University Hospital,
              Oslo, Norway
Classification of fractures in
the proximal femur
The Comprehensive AO/ASIF Classification (Müller et
     al. 1990) of fractures in the proximal femur
The comprehensive classification of
neck fractures of the proximal femur
Pauwel’s classification of neck fractures
(1965) (based on the angle the fracture line with the
resultant of forces (R))
           Garden’s classification
(based on the relationship of the medial trabeculae in the
                     head and pelvis)
Reported annual incidence of hip fractures
per 100 000 of population (Parker and Pryor
1993)
   •   Sweden                   165
   •   Canada                   103
   •   Finland                  91
   •   UK                       86
   •   USA                      80
   •   Malayasia                70
   •   Israel                   59
   •   Korea                    34
   Number of hip fractures in
   Norway 1979-1999:

              population 4 000 000

• 1979: 6 800
• 1989: 9 900                  12000


• 1999: 11800 (290 per 100 000)10000

                                8000

                                6000

                                4000

                                2000

                                   0
                                       1979   1989   1999
We have to define our problem
    500000
               Norwegians aged 80 year and more in 2050
               Life expectancy in year 2050
               is estim ated to be 80 years for men and
               84.years for women                                                      8.3%
    400000



A
    300000
g
i                                                                   4.3%   4.5%
    200000
n                                                     3.8%
                                                             4.1%

g
    100000
                                        2.0%                               prognosis
              1.3%       1.4%

              1900 1930                 1997 2020 2050 2020
             1900 1930 1960 1960 1990 2000 2 2000
                              1990 1997
   Cooper C, Campion G, Melton
         LJ (1992) Osteoporosis
                  Int;2:285-289
• 6.25 million is an estimated number of hip
  fractures world wide by 2050
• Increasing world population and increasing
  life expectancy seems to be the most
  important reason for this increase
Why do we experience an
increase the number of
fractures?
 • Falling frequency increases with age
 • Porosity of bone increases with age


           Cooper C, Campion G, Melton LJ
           (1992)
            Osteoporosis Int;2:285-289
Determinants of fracture risk
-Neuromuscular function
-Environmental hazards
-Time spent at risk       Risk of fall


Type of fall
Protective responses       Force of impact
Energy absorption
                                     Risk of fracture
Geometry of bone              Strength of bone
Bone mineral mass
Quality of bone
Choice of Treatment policy
Fracture related pattern of femoral
neck fractures representing risk for
osteofixation failure, non-union and
avascular necrosis

• Grade of dislocation (Garden 1972, Thorngren 1991)
• Size of head fragment (Benterud et al. Acta Orth Scand
  1994)

• Posterior comminution (Benterud et al.1997)
• Osteoporosis (Bentley 1972, Riska 1969, Anderson 1969,
  Thorngren 1995)
  Fracture related pattern of femoral
  neck fractures leading to a
  “treatment policy”..
  • Impacted fractures are reported to have less
    incidence of non-unions (Bentley G, JBJS;50
     B:551,1968, Raymakers, 1993)
  • Impacted fractures develop less segmental
    collapse in avascular necrosis of the head ?
Crawford reported 12 % of avascular necrosis in 50 impacted
fractures out of 339 femoral neck fractures with an overall
incidence of avascular necrosis in 37% (Crawford H, JBJS; 47
A:830,1965)
Preservation of the femoral head
  or hemi (total) arthroplasty?
Julius Nicolaysen (1831-
1909), from Bergen, worked
as a Professor in Oslo. He
nailed a medial femoral neck
fracture in 1893, 2 years
before Wilhelm Konrad
Røntgen discovered the X-
ray
Femoral neck fractures in the young
or “young geriatric” patient have
different aspects as to the older
patient..
• Osteoporosis is frequent not the main
  problem
• Fracture pattern is often different as to the
  older patient
• Prosthetic replacement as a primary
  treatment alternative has to be chosen with
  greater care than in the older patient
Transcervical and subcapital femoral neck
fracture (31 B and 31-C3) in the “young
geriatric” patient


• Hip replacement (hemi or total arthroplasty)
  represents an internal amputation with all its
  implications
• Preservation of the joint (as in all joint
  fractures) should be what we aim at in the
  treatment
Secondary failures like secondary osteofixation
failure as well as segmental collapse may be handled
by secondary arthroplasty



• “Primary and secondary Charmley-Hastings
  hemiarthroplasty in displaced femoral neck
  fractures and their sequelae”
  Benterud JG, Kok WL, Alho A. In: Ann Chir Gynaecol
  1996; 85(1):72-6
What do we do with the impacted
femoral neck fracture (31-B2) ?

Functionally treated:
 No.of Patients           Age   Instable
  59                    15-69    2 = 3%

   73                   70-94   16 = 22 %


   Raaymakers 1993
What do we do with the impacted
femoral neck fracture (31-B2) ?
In the literature we find:

Instability:

After early mobilisation
without weightbearing:       8-19%


After immediate
full weight bearing:         32-65 %
What do we do with the impacted
femoral neck fracture (31-B2) ?

 Mortality in impacted femoral neck
 fractures:

 Operative treatment      >   10 %


 Conservative treatment        1.8 - 3.3.%
 (Raaymakers 1993)
  What do we do with the impacted
  femoral neck fracture (31-B2) ?


“It is impossible at the          Retroversion is not
time the patient presents         an important
himself to predict which          reason for higher
fractures will undergo            instability
desimpaction”

(Bentley,Crawford, Judet,
                                     (Raaymakers 1993)
Asser, Hansen, Famos,Jeannaret)
  What do we do with the impacted
  femoral neck fracture (31-B2) ?
 Conclusion may be as follows:
Age less than 70: Internal fixation in
                  situ


Age more than 70:   Conservative treatment. If
                    secondary dislocation or
                    AVN: Arhroplasty
In dislocated femoral neck fractures..
Timing of Surgery
• As preservation of the femoral head is the
  main goal of our treatment surgery should
  be performed as soon as possible and latest
  within 6 hours
• The value of decompression of the
  intracapsular haematoma still is unknown
In dislocated femoral neck fractures..
Timing of Surgery. If not immediate ?

• The value of immobilisation in traction is
  questionable in concern of development of
  avascular head necrosis
• Positioning of the hip in the most
  comfortable position to the patient probably
  also is the position where the intracapsular
  pressure is at lowest
   Is the viability of the femoral head
                predictable?

Preoperative             Intraoperative
                     • Intraoperative by
                       bleeding?
• By fracture
  classification?    • Intraoperative by
                       measuring of electric
• By scintigraphy?
                       potential with
• MRI                  temporary implanted
                       platine electrodes and
                       gas insuflation
                       (H2O2)?
    In femoral neck fractures..




Is the viability of the
 femoral head
 predictable?

     MRI
Reduction technique in
intracapsular fractures of the
femoral neck
• Loosen the fracture
  by “unpack” it
• After having
  obtained the
  reduction “pack the
  fracture” and then
  fix it

                        Mark Flynn injury 1973
Impacted fracture                    Non displaced fracture
          Impacted
          fracture




          Displaced fracture   Reduction manoeuvre (Leadbetter)
Intracapsular fractures of the
femoral neck
                             ventral
• Internal rotation of the
  foot should result in
  the femoral head, neck
  and shaft all appearing
                             dorsal
  in a straight line with
  no residual anglulation
  at the fracture site
Choice of Implant
Choice of Implant
• Cannulated bone screws
• Non cannulated bone screws
• Nails with hooks (Hansen nails)
• 130 0 Angle blade plate

• Sliding Screw Plate Systems
 (DHS, HCS)
       Implant demands..
• The implant shall provide stability
  - prevent dislocation in varus
  - prevent dislocation in retroversion
  - prevent rotational micromovements
• Allow axial sintering along the implant
  without penetrating into the joint
• In case of delayed union and non union
  migration into the joint/pelvis should not be
  possible
Choice of Implant:
Sliding Screw Plate System
       Choice of Implant
Benterud JG, Husby T, Nordsletten L, Alho A:
“Fixation of displaced femoral neck fractures
with a sliding screw plate and a cancellous screw
or two Olmed screws. A prospective study of 225
elderly patients with a 3-year follow up”.

Ann Chir Gynaecol 1997; 86 (4) 338-42
       Choice of Implant
Ann Chir Gynaecol 1997; 86 (4) 338-42


 Conclusions.   Both treatment methods
                resulted in high rate of osteofixation
                failures (18.5 % in the SSP group
                and 19.5 % in the Olmed group)
                and non-unions (6.2 % and 8.5%
                respectively)
            Choice of Implant
• In 31- B2 fractures of
  the “young geriatric”
  patient a 4 hole DHS
  with an antirotational
  screw, however, is the
  implant of choice. The
  fixation on the tensile
  side of the femur and
  gliding cylinder for
  the screw provides
  stability over time
Choice of Implant




            Angle blade plate
            and cancellous screw
Femoral neck fractures:
If screws: Two or three screws? Position of
the screws? Dimensions of the screws?




         Three screw fixation
         technique in fixation of
         cervical fractures of the
         proximal femur
            Choice of Implant




Screws with head and washer
preventing axial migration in
instability                     Screws without head
                                and equal diameter
                                of thread and shank
 Fate of the medial neck fracture
            after ORIF
• Early osteofixation failure in 8-16 %
• Non-union in 8 -10%
• AVN in 6-10 %

• This makes an overall failure rate of 20-
  30%
• but- in the first year after a medial neck
  fracture 25 % of the patient are dead to
  unrelated fracture desease
Classification of trochanteric fractures (31-A 1-3)
Bone mass related to age in
cancellous bone and cortical bone
  Bone mass



         Trochcanteric area




        Neck of the
       femur


                      50 years   100 years
                                             Age
   Fractures in the proximal Femur at
   Aker Hospital, Oslo,Norway1999

Diagnose              No    Median age    male   female

Cervical Frx          282   84 (29-104)    53     229

Pertrochanteric Frx 186     88 (54-102)    75     111

Subtrochanteric Frx    37   86 ( 39-95)    20      17
                      505                 148      357
Biomechanichs of the proximal femur
Biomechanichs of the proximal femur
Biomechanichs of the proximal femur
Fracture pattern reflects biomechanichs
of the proximal femur in different stages by falling

    • Falling activates
      tensile forces of the
      muscles
    • Falling induces
      rotation of the femur
      on the fixed leg
    • Forces act on the
      trochanter by direct
      contact at the end of
      the fall
 In unstable trochanteric fractures in the
   elderly the implant chosen have to:

• respect the instability of the fracture
• allow fracture impaction during motion
  without fixation failure
• secure retention of the fracture in acceptable
  position during healing
• build a biomechanical construct with the
  bone allowing early weight bearing
       31-A3.3 Fracture. DHS and TSP
• sliding screw -plate
  system allowing the
  fracture sintering
• plate on the tensile site
  neutralising tension
  forces
• Trochanteric
  Supporting Plate
  preventing femoral
  shaft medialisation
• Additional
  antirotational screw        Week 0   Week 8
          31-A3.3 Fracture., The -nail

• sliding screw-nail
• nail in the centre of the
  femoral axis
• reduction of the lever
  arm
• no neutralisation on
  the tensile side
• sintering in varus with
  “cutting through”
        31-A3.3 Fracture. The -nail




Day 1              Day 126        Day 160
 In unstable trochanteric fractures in the
   elderly the implant chosen have to:

• respect the instability of the fracture
• allow fracture impaction during motion
  without fixation failure
• secure retention of the fracture in acceptable
  position during healing
• build a biomechanical construct with the
  bone allowing early weight bearing
Fractures at the tip of the short
             - nail




          51 days
  Fractures at the tip of the nail
• Aune et al. Acta Orthop Scand 1994; 65
  (2):127-30: HCS vs.Gamma nail
  378 patients:               5.6 %
• Madsen et al: J Orthop Trauma 1998
  Vol.12. No 4 50 patients 2.9%
• Osnes et al. Norw.proceedings 1998:
  379 patients                5.3%
Stress measurements at the end of the nail. A
comparative study between the -nail and the
PFN. E.Euler. LMU München 1999
A photoelastic loading study




Stress by cyclic loading with
700 N up to 7 times as high
in the Gamma nail as in the PFN




   DHS     +     TSP
      The Medoff sliding plate

• A sliding screw plate
  system allowing
  sintering along the
  neck axis as well as
  along the femoral axis
The Medoff sliding plate used in a 31-A3.2 fracture with
                 reversed fracture line
  "A great responsibility rests on the surgeon who
     introduces a new method of treatment.
    The desire to have a new idea published
is so great that the originator is often led astray,
and the method is broadcast before it has been
          proved worthwhile and before
        the technique has been perfected."

                 Smith-Peterson, Cave &
                               Vangorder
                Archives of Surgery 1931
Thank you for your attention

				
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