Choice of implant in unstable trochanteric fractures Knut

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Choice of implant inunstable trochanteric
fractures

• Knut Strömsöe, MD PhD, Orthopaedic Department,
  Aker University Hospital,
• Oslo, Norway
• Hip fractures
• 2000
• State of the Art
• Amsterdam may 2000

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Bone mass related to age in cancellous bone and
cortical bone
Bone mass
Trochanteric area
Neck of the femur
50 years
100 years
Age
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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
148 357
505
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Lets start with epidemiology as we see it at
Aker..
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Fractures in the proximal Femur at Aker
University Hospital, Oslo,Norway1999
Diagnose No Median age Stay in H. Min
Max Mean
Cervical Frx 282 84 (29-104) 2412
1 64 8.6
Pertrochanteric Frx 186 88 (54-102)
1906 1 56 10.2
Subtrochanteric Frx 37 86 ( 39-95)
416 1 50 11.2
9.85
505
4734
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Classification of trochanteric fractures (31-A
1-3)
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Fractures in the proximal Femur at Aker
Hospital, Oslo,Norway1999
Type of Fracture male female
Total
31-A 1 33
82 115
31-A 2 45
39 84
31-A 3 17
7 24
95 128 223
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Biomechanichs of the proximal femur
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Biomechanichs of the proximal femur
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Biomechanichs of the proximal femur
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• Differences in strength between cancellous
  and cortical bone in the same individual

Alho A, Strömsöe K, Höiseth A. Pairwise
strength relationship of cortical and cancellous
bone in human femur- an autopsy study Arch
Orthop Trauma Surg 1995
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Different strength in cortical and cancellous
bone in the same individual may explain...

• the different pattern in trochanteric fractures
  at different age groups
• that male patients with good muscular strength
  more frequent suffers fractures of AO type 31-A2
  and 3 (unstable fractures) whereas women
  frequently suffers fractures of AO type 31-A 1
  (stable fractures)

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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

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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

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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 8
Week 0
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31-A3.3 Fracture., The ?-nail

• sliding screw-nail
• nail in the center of the femoral axis
• reduction of the lever arm
• no neutralisation on the tensile side
• sintering in varus with cutting through

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31-A3.3 Fracture. The ?-nail
Day 160
Day 1
Day 126
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Fractures at the tip of the short ?- nail
51 days
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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

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C.Piene-Schröder, Ortopaedic Department, Aker
University Hospital, Oslo, NorwayA retrospective
study on 306 short ?-nails over a 2 year period
(1994/95). Norwegian Proceeding 1997

• 82 female, 18 male
• median age 83.9 (78.9-88.9) years

• 11.2 12 mm nail
• 88.8 11 mm nail
• only 11 was locked distally with one or two
  screws

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C.Piene-Schröder, Ortopaedic Department, Aker
University Hospital, Oslo, NorwayA retrospective
study on 306 short ?-nails over a 2 year period
(1994/95). Norwegian Proceeding 1997
Fracture Total Aker Follow up
Norwegian MSS
Stable 48.2 43.6 48.3
Unstable 41.0 43.6 43.7
Subtrochanteric 12.8 8.0 8.0
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C.Piene-Schröder, Ortopaedic Department, Aker
University Hospital, Oslo, NorwayA retrospective
study on 306 short ?-nails over a 2 year period
(1994/95). Norwegian Proceeding 1997

• 95 hips not followed up (31)
• 69 patients not alive
• 9 patients did not appear as scheduled
• 14 patients were not in condition to appear for
  control
• 3 patients refused to appear for a clinical
  control

• All records were consulted
• 211 patients had a clinical and radiological
  control gt 3 months post injury (69)
• median time between injury and follow up 13.5
  months (7-23)

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C.Piene-Schröder, Ortopaedic Department, Aker
University Hospital, Oslo, NorwayA retrospective
study on 306 short ?-nails over a 2 year period
(1994/95). Norwegian Proceeding 1997

• 5 patients had local infections
  (3 superficial, 2 deep)
• 2 patients with DVT
• 6 patients had shortening with complaints

• 23 patients needed reintervention (8.9)
• 9 patients (2.9) suffered a fracture of the
  femur at the tip of the nail median 24 (
  19.5-51.7) days after surgery
• 5 patients had cutting through of the screw

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C.Piene-Schröder, Ortopaedic Department, Aker
University Hospital, Oslo, NorwayA retrospective
study on 306 short ?-nails over a 2 year period
(1994/95). Norwegian Proceeding 1997

• All fractures but one healed.
• Sintering in varus more than 50 were observed in
  34 of the patients

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Stress measurements at the end of the nail. A
comparative study between the ?-nail and the PFN.
E.Euler. LMU München 1999A 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
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(No Transcript)
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The Medoff sliding plate

• A sliding screw plate system allowing sintering
  along the neck axis as well as along the femoral
  axis

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The Medoff sliding plate used in a 31-A3.2
fracture with reversed fracture line
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"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 technic has been
perfected."
Smith-Petersen, Cave Vangorder Archives of
Surgery 1931 23 p.715
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Conclusion concerning the choice of implant in
the treatment of unstable fractures in the
proximal femur
The DHS with TSP seems today to be the device
against which any new design are to be judged in
the treatment of unstable trochanteric fractures
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In the subtrochanteric area any long nail
with different locking options (UFN or
any reconstruction nail) is the device of choice
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Thank you for your attention
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31-AO 2.2 92 year old female
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31-AO 2.2 92 year old female
Post operative. Anatomical reduction and
fixation with a 4 holes DHS, Trochanteric
Supporting Plate (TSP) and an antirotational
screw
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C.Piene-Schröder, Ortopaedic Department, Aker
University Hospital, Oslo, NorwayA retrospective
study on 306 short gamma nails over a 2 year
period (1994/95). Norwegian Proceeding 1997

• 82 female, 18 male
• median age 83.9 (78.9-88.9) years
• 54.2 without walking aids preinjury
• 24 dementia senilis
• 18 in nursing home preinjury

• 11.2 12 mm nail
• 88.8 11 mm nail
• only 11 was locked distally with one or two
  screws

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Sven Johansson
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Classification of fractures in the proximal femur