Hip Fractures

The Hip Fractures, MD, PhDOverviewIncidence is highest in >65 years of age but also in young adults due to RTA320,000 admission in the US each year, 20,000/year in TaiwanF>M15-20% die within 1 year of fracture, M>F Function recovery 30-40%, dependent life with painTwo types: intracapsular and extracapsular

2Anatomy

3Anatomy of FemurValgus reduction: Reduction should leave neck shaft angle between 130-150 degAccepable reduction may have up to 15 deg of valgus>185 deg at risk of AVN Varus reduction:Results in higher non-union rateNot an anatomical reductionmay lead to post op displacement (Weinrobe 1998)Angulation: reduction should be between 0-15 deg of anteversion

4Risk FactorsAge: >65 yearsCo-morbid factors: medical diseasesGender: FRTA

5Risk FactorsNutrition: lack of calcium and Vit D in diet, eating disorders (anorexia), high caffeine intakeSmokingAlcoholMedication: steroids, anticonvulsants, diureticsSedative lifeEnvironmental factors: loose rugs, dim lighting, cluttered floorsFalls.

6 Osteoporosis:

PresentationP/C: severe pain, bruising, swellingUnable to weight bear on that leg.O/E: may have shortened leg with external rotation

8InvestigationsFull history and physical examAssess patient as per ATLS (Advanced Trauma Life Support) protocolX-rays AP and lateral, CT, MRI, bone scanECG, CXRMedicationsTiming of surgeryAnesthesiaPost-op ICU care

9Intracapsular FracturesClassificationClassified on geographical position: Intracapsular: SubcaptialTranscervicalbasicervicalExtracapsular:Intertrochantericsubtrochanteric

11Garden ClassificationGarden I: incomplete fracture of the femoral neckGarden II: complete fracture without displacementGarden III: complete fracture with partial displacementGarden IV: complete fracture with full displacement

12Pauwels ClassificationThe more vertical the line the greater the risk of non union because increased shear stresses across the fracture

13Subcapital Fracture:Most common intracapsular fracture of the hipX-ray: white line of increased density of impacted bone may be seen at base of femoral head

14Transcervical FractureOccurs across neck of femurEasy to view when hip x-ray obtained in internal rotationa/w varus deformity

15Basicervical FractureBase of femoral neckAre intracapsular two part fractures with fracture plane running along line of capsular insertion

16Management of Femoral Neck FractureConservative: analgesia, bed rest, tractionif pt not willing to consent for surgery or if not expected to survive surgery Surgical: Manninger et al showed significant reduction in osteonecrosis and segmental collapse if performed within 6 hrHead sparing: screws, CHSHead sacrificing: hemi, THR17Young PatientsNon-displaced fracturesAt risk for secondary displacement Urgent ORIF recommendedDisplaced fracturesPatients native femoral head bestAVN related to duration and degree of displacementIrreversible cell death after 6-12 hoursEmergent ORIF recommended

18Elderly PatientsOperative vs. Non-operativeDisplaced fractures Unacceptable rates of mortality, morbidity, and poor outcome with non-operative treatment [Koval 1994]Non-displaced fractures Unpredictable risk of secondary displacementAVN rate 2XStandard of care is operative for all femoral neck fractures

19Acceptable Reduction of femoral Neck FractureLowells Alignment theoryoutline of femoral head & neck junction will have convex outline of femoral head meeting concave outline of femoral neck regardless on all views Image should produce an S or reverse SIf image is a C fracture is not reduced

20 Gardens Alignment Index:

Refers to angle of compression trabeculae on AP relative to longitudinal axis of femoral shaft and angle of the compression trabeculae on lateral to the femoral shaftAcceptable range of 155-180 deg on both viewsIf >/< higher incidence of AVN

21 Treatment choices:1: Cannulated Hip screws.2: Dynamic Hip Screw.3: Hemiarthroplasty Hip.4: Total Hip Replacement. Cannulated Screws.

23 Cannulated Screws (Richard)Used for undisplaced femoral neck fracturesGood for fracture which are more horizontalKrastman (2004): 112 pt study had 95% consolidation rate with 2 cannulated screws in intracapsular stable fracturePosition of screw did not interfere w consolidationRates negatively affected by inadequate anatomical reduction and unstable fractures

24 Cannulated Screws.Fixation: Multiple screws in parallel No advantage to > 3 screwsUniform compression across fractureFixation most dependent on bone densityScrew locationAvoid posterior/ superior quadrantBlood supplyCut-outBiomechanical advantage to inferior/ calcar screw (Booth 98)25 Cannulated Screws.

Subtrochanteric fracture through screw insertion site26Dynamic Hip ScrewMore stable fixationLarger wound and operation timeSacrifices large amount of bonePrevent subtrochanteric fractureAnti-rotation screw often needed?

27Hemiarthroplasty Hip: Indications:Poor general healthPathological hip fractureSevere osteoprosisPhysiological age >70 Inadequate closed reductionPre-existing hip diseaseContraindication:Pre existing sepsisYoung patientPre-existing disease of the acetabulum28Hemiarthroplasty Hip:Hemi associated with (Luyao 1994, lorio 2001)Lower reoperation rate (6-18% vs. 20-36%)Improved functional scoresLess painMore cost-effective

29 Bipolar Bipolar theoretical advantagesLower dislocation rateLess acetabular wear/ protrusionLess PainMore motionBipolar DisadvantagesAcetabular wear

30Hemi Vs. THRDislocation rates:Hemi 2-3% vs. THR 11% (short term)2.5% THR recurrent dislocation (Cabanela1999)Reoperation:THR 4% vs. Hemi 6-18%DVT / PE / Mortality No differencePain / Function / Survivorship / Cost-effectivenessTHR better than Hemi (Lu Yao 1994) (Iorio 2001)

31Femoral Neck Fracture ComplicationsFailure of FixationInadequate / unstable reductionPoor bone qualityPoor choice of implantSubtrochanteric fractureOsteoporosisAvoiding multiple drillDiamond or reverse triangle screw positionWider distanceAbove lesser trochanterTreatmentElderly: ArthroplastyYoung: Repeat ORIF Valgus-producing osteotomy Arthroplasty

32 Femoral Head AVN5-8% Non-displaced fractures20-45% Displaced fracturesIncreased incidence withINADEQUATE REDUCTIONDelayed reductionInitial displacementassociated hip dislocation

33Femoral AVNTreatmentElderly patientsOnly 30-37% patients require reoperationArthroplastyResults not as good as primary elective arthroplastyGirdlestone Resection Arthroplasty

34Femoral AVNTreatmentYoung PatientsProximal OsteotomyLess than 50% head collapseArthroplastySignificant early failureArthrodesisSignificant functional limitations** Prevention is the Key **35Extracapsular FracturesInter-trochanteric fracture.Sub-trochanteric fracture.36Intertrochanteric FractureMost common extracapsular hip fracturea/w varus deformityClassified by Evans as stable or unstableMost commonly used classification is Jensen where type 1&2 are stable and 3-5 are unstable

37 Jensen Classification

38

OTA classificationType 31 Subtrochanteric FractureClassified by Seinsheimer: divided into undisplaced, two part, and comminuted

40 Seinsheimer classification

41Isolated fracture of Greater Trochanter:Occurs mainly in osteoporotic femalesResult of a fall on the greater trochanter or avulsion type fracture from pull of gluteus medius insertion

42Management of Extra-capsular Fractures:CHSIM nailing

43Compression Hip ScrewCompression hip screws with a plate have gained high popularity for the treatment of intertrochanteric fracturesThese implants provide secure fixation and controlled impaction of the fracture, easy technique The rate of complications is relatively low with most frequent mode of failure being cut out of the screw from the femoral head (Davis 1990)

4445

Compression Hip ScrewPercutaneous Compression PlateInserted at parallel to femoral diaphysis through a small incision therefore less blood lossShorter operating time compared to DHS (30 min)Neck screws are telescopic and provide double axis fixation in femoral neck increases rotational stability by fracture compression and preventing collapse of neck (Giancola 2004)

46Disadvantages of CHSExcessive slidingShorteningLateral wall insufficiencyEspecially poor in osteoporotic and comminuted casesIM NailingIntramedullary nails combine the advantages of intramedullary fixation with those of a sliding screwMechanically, the shorter lever arm of the intramedullary nail decreases the tensile strain on the implant and reduces the risk of failure of the implant (Kaufer medline)Rates of clinical failure range from 0-4.5% (Dean 2004)Has a better mobility score at 1 year when compared to sliding hip screw (Hardy 1998)48IM NailGamma 3PFN

Inserting siteLag screw positionNail head diameter49IM nailing Vs CHSThere is no advantage to an intramedullary nail versus a sliding compression hip screw for low-energy pertrochanteric fractures, specifically with its increased cost and lack of evidence to show decreased complications or improved patient outcome (Saudan 2002)

Two trials (n = 65 with reverse and transverse fractures at the level of the lesser trochanter) found intramedullary nails (Gamma nail or PFN) were associated with better intraoperative results and fewer fracture fixation complications than extramedullary implants (a 90-degree blade plate or dynamic condylar screw) (Parker 2008)

5051Adequate operative position

52Valgus fracture reduction

53Inferior lag screw As close as possible to the inferior cortex of femoral neck Increase bone holding power Prevent screw cut-out

Adequate lag screw position

Middle in lateral view10 mm below hip joint

Tip-apex distance55Void filling with calcium phosphate cement

5556HOW?

Osteoporotic treatmentsBMD measurementSupplement of Ca and Vit DAnti-osteoporotic agentsBone resorption inhibitionNew bone formation Thank you!58