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MANAGEMENT OF FEMORAL FRACTURES MODIFICATIONS OF THE GOLD STANDARD

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... posterior position in piriformis fossa. Guide pin. PIRIFORMIS ENTRY ... Posterior piriformis fossa in line with proximal femoral canal. Minimizes hoop stresses ... – PowerPoint PPT presentation

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Title: MANAGEMENT OF FEMORAL FRACTURES MODIFICATIONS OF THE GOLD STANDARD


1
MANAGEMENT OF FEMORAL FRACTURESMODIFICATIONS OF
THE GOLD STANDARD
  • Madhav A. Karunakar
  • Carolinas Medical Center

2
GOLD STANDARD
  • Debatable
  • Reamed Statically Locked Antegrade Piriformis
    Entry Nail
  • Supine on Fracture Table

3
MODIFICATIONS
  • Insertion Site Options
  • Antegrade versus Retrograde
  • Piriformis versusTrochanteric
  • Positioning
  • Fracture Table
  • Supine versus Lateral
  • Free leg without traction

4
INSERTION OPTIONS
  • ANTEGRADE
  • PIRIFORMIS
  • TROCHANTERIC
  • VS.
  • RETROGRADE

5
PIRIFORMIS ENTRY
  • For the past 25 years, the correct start point
    for femoral nailing has been considered to be the
    piriformis fossa (just medial to GT and posterior
    to the gluteus medius tendon)
  • Palpable and seen on xray

6
PIRIFORMIS ENTRY
Guide pin

Degree of overlap indicates posterior position in
piriformis fossa
7
PIRIFORMIS ENTRY
Guide pin

Less overlap indicates more anterior position in
piriformis fossa, appropriate for piriformis
cephalomedullary device (eg RT Recon Nail)
8
PIRIFORMIS ENTRY
  • Early antegrade nails designed for this starting
    point
  • Based upon anatomy of proximal femur
  • Posterior piriformis fossa in line with proximal
    femoral canal
  • Minimizes hoop stresses
  • More important with stainless steel, less
    anatomic nail designs

9
PIRIFORMIS ENTRY
  • Anatomy of the proximal femur
  • Hoop stresses

Graph depicts variation in hoop stresses
generated by various nail types, A-E Johnson KD,
Tencer AF. Biomechanics in Orthopaedic Trauma,
Martin Dunitz Ltd, 1994.
10
PIRIFORMIS ENTRY
Johnson KD, Tencer AF. Biomechanics in
Orthopaedic Trauma, Martin Dunitz Ltd, 1994.
11
ANTEGRADE PIRIFORMIS ENTRY
12
PIRIFORMIS CHALLENGES
  • Problem patients
  • Obese
  • Muscular
  • Hooked trochanter

13
RETROGRADE ENTRY
  • RELATIVE INDICATIONS
  • Ipsilateral Fractures
  • Femoral Neck
  • Intertrochanteric
  • Acetabular
  • Tibia
  • Patella
  • Bilateral Femurs
  • Ipsilateral TKA
  • Polytrauma
  • Obesity
  • Pregnancy
  • Distal Fractures

14
RETROGRADE ENTRY
PCL
15
RETROGRADE ENTRY IMN
16
COTS - PRCT
  • Nonunion
  • Reamed 2 /121 (1.6)
  • Unreamed 8/107 (7.5)
  • 1 deep infection
  • No malunions

JBJS 2003
17
CONCERNS REGARDING RETROGRADE
  • Cartilage Injury?
  • Patello-femoral joint mechanics
  • Nonunion and implant failure with migration into
    knee
  • Intraarticular infection
  • Nail removal

18
RISKS OF PROXIMAL INTERLOCKING
Tornetta, JOT 1998
19
TROCHANTERIC ENTRY
  • Gaining in popularity
  • Easier to insert
  • Easier in obese pts
  • Versatile for proximal femur fractures
  • Safer for adolescent fxs
  • Less injury to abductors
  • Less risk femoral neck injury

20
TROCHANTERIC ENTRY
  • Where is it?

Entry Portals Size Varies from 10-17 mm Hip
fracture nails versus reconstruction type nails
21
PIRIFORMIS ENTRY
Piriformis starting point
22
TROCHANTERIC ENTRY
Forces nail to make a turn in proximal femur
Trochanteric starting point
23
TROCHANTERIC ENTRY
Guide pin
?? Need lateral image to judge
anterior-posterior position
24
What about the biology of the abductors?
Trochanteric Start Point Gamma Nail
Ream away 25 - 50 of tendon
CORR (407) February 2003
25
MODIFIED MEDIAL TROCHANTERIC PORTAL
  • Medial tip of trochanter along trochanteric ridge
  • Center of neck trochanteric junction on lateral
  • No damage to the medius tendon in cadaveric study

Perez et al, JOT 2007
26
(No Transcript)
27
TROCHANTERIC ENTRY
  • Disadvantages
  • Varus malreduction of proximal fractures
  • Fracture comminution
  • Is it really easier to access?
  • How much difference is there between modified
    portal and piriformis portal.

28
THOSE WHO FORGET HISTORY
  • Tip of the trochanter start point
  • Kuntscher, Bohler, Grosse
  • Trochanteric Starting point is not collinear with
    IM canal
  • Fracture Comminution and varus malalignment can
    occur
  • Winquist, Johnson

29
ANTEGRADE TROCHANTERIC ENTRY
Conclusions Equivalent results to Piriformis
nail
30
PIRIFORMIS VS TROCHANTERIC ENTRY POINT
  • No evidence that lateral start point has any
    technical advantage or that the outcomes in terms
    of function or entry point symptoms are better
    than piriformis start point
  • There is a risk of fracture comminution and
    malalignment with the use of a nonlinear entry
    point

31
POSITIONING IN TRACTION
  • Supine
  • Lateral

32
POSITIONING IN TRACTION
  • Advantages
  • Familiar
  • Need fewer hands
  • Mega Traction!
  • Disadvantages
  • Set Up Time
  • Pudendal Nerve Palsy
  • Compartment Syndrome

33
Compartment Syndrome
34
SUPINE FRACTURE TABLE
  • Advantages
  • Easier setup
  • Spine Clearance in polytrauma
  • Disadvantages
  • Starting position
  • Reduction in proximal fractures
  • Obese patients
  • Pudendal nerve palsy

35
LATERAL FRACTURE TABLE
  • Advantages
  • Easier insertion point
  • Proximal fractures reduces flexion and varus
    deformity
  • Disadvantages
  • Longer positioning time
  • Pudendal nerve palsy
  • Rotational malunion
  • Spine Clearance

36
BILATERAL FEMUR FRACTURES
37
FREE LEG POSITION
  • Supine
  • Shortest set up time
  • Easy Starting portal
  • Ideal for Polytrauma /- Bilaterals
  • Need Extra Help

38
FREE LEG POSITION TIPS
  • Bump positioned too far lateral
  • Patient NOT at edge of table

39
SUMMARY
  • Piriformis Nail is the Gold Standard
  • High union rate few complications
  • Retrograde Nail has role in trauma
  • Trochanteric Nail still being determined
  • Fracture Table still useful
  • Avoid well leg holder
  • Free leg in trauma center and with help
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