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Re-written by: Daniel Habashi Intertrochanteric Hip Fractures Slide 2 Intertrochanteric Hip Fracture objectives Incidence Mechanism of injury Physical findings X-ray assessment Classification scheme Treatment goals Treatment options Treatment techniques Complications Outcomes Failure of treatment Salvage procedures Slide 3 Intertrochanteric femur From the extra-capsular femoral neck To inferior border of the lesser trochanter Slide 4 Incidence 250K hip fractures a year Demographics 90% over 65 years of age F>M Peak around 80 y. Slide 5 Etiology Osteoporosis Low energy fall common High energy rare Slide 6 Prevention Prevention and active treatment of osteoporosis Fall prevention Minimize fall impact Slide 7 Physical presentation Involved extremity Short External rotated Slide 8 Radiographs Plain films AP pelvis Cross table lateral Slide 9 Special studies CT scan rarely indicated Bone scan occult fractures, sensitive at 72 hours MRI occult fractures, sensitive in 1 st 24 hours Slide 10 Classification Multiple classifications Stable vs. unstable Evans Evans-Jensen Muller AO/ASIF OTA Muller AO-ASIF system Slide 11 Classification Stable Resists medial and compressive loads With anatomic reduction and fixation THERE WAS A PICTURE HERE OF A FRACTURE Slide 12 OTA AO/ ASIF Classification 31-A3 Two part fracture Comminuting Fracture enters the lateral cortex Reverse obliquity fracture Unstable Slide 13 OTA AO/ASIF Classification There was also 31-A2 but he changed the slide in a matter of a second so:/ Slide 14 Goals of treatment Obtain A stable reduction Internal fixation Good position Mechanically adequate Permit immediate transfers and early ambulation Slide 15 Intra-operative positioning Hemilithotomy position Slide 16 Intra-operative fluoroscopy 2 pictures of it. Nothing important Slide 17 Fracture reduction Neck / shaft axial alignment Translational displacement Anatomic reduction of individual fragments is not necessary Reduction maneuver Traction Internal rotation Slide 18 Implant options Compression hip screw and side plate Intramedullary sliding hip screw Calcar replacing prosthesis Slide 19 Implant positioning Centered in the femoral head ( AP VIEW and LAT VIEW) Etc etc ect Slide 20 Tip-apex distance (TAD) TAD strong predictor of cut out TAD under 25mm Failure approaches zero TAD over 25mm Chance of failure increases rapidly Slide 21 Implant options Intramedullary Sliding Hip Screw Decreased implant bending strain Potential percutaneus technique Inter-Troch Shaft Reverse obliquity Pathologic shaft fracture Slide 22 Implant options Calcar replacing prosthesis Indications Ewtc etc etc Slide 23 Reverse obliquity fracture Slide 24 Cement augmentation Severe osteopenia Polymethyl methacrylate (PMMA) Improves screw purchase Augment deficient medial cortex Prevent screw cut out Slide 25 Rehabilitation Mobilize Weight bearing as tolerated Etc. etc.etc. Slide 26 Failed fixation Screw cut out Screw barrel disengagement Slide 27 Salvage of failed fixation Slide 28 Outcome Mortality 7-27% 3 months post-op # of medical problems # of post-op complications Function 40% pre-injury ambulatory status 40% ambulatory increased dependence 12% household ambulates 8% non ambulates