Surgical treatment of osteoporotic proximal femoral fractures Rozkydal, T., Reška, M., Tomáš, T. RTKA St Anna 1 1st orthopaedic dpt., MU head: ass. prof. P. Janíček, CSc. 1st dpt. of surgery, MU head: prof. I. Čapov, CSc. St. Anna Hospital, Brno, Czech republic Proximal femoral fractures - big challenge for orthopaedic surgeons Incidence USA (280 mil. inhab.) 310 000 / year U.K. ( 60 mil. inhab. ) 80 000 / year Czech republic (10 mil. inhab.) 18 000 / year World 1.8 million / year 95 % over 65 y. of age 5 % under 65 y. of age 90 % in osteoporosis Incidence of proximal femoral fractures Kopie - Prep-Mikřát-1 Features Lower bone quality More comminution of bone fragments Lower fixations of implants in the bone Higher demands on perfect technique of internal fixation ch křivánková 1 Patients with fractures of proximal femur • •Mortality 20 % within one year • •Only 40 % get their previous quality •of life • •20 % require care in long term facility Proximal femoral fractures St. Anna Hospital, Brno, Czech republic Period 2006 - 2010 y. Number of patients 612 Male 184 Female 428 The mean age 72 y. (26- 96) Proximal femoral fractures n= 612 Intracapsular 142 Trochanteric 342 Subtrochanteric 127 Intracapsular fractures Usually in elderly Osteoporotic Femoral head - varus - retroversion Comminution of posterior aspect of the femoral neck Disruption of the blood supply Complications: Avascular necrosis of the femoral head Nonunion F AO klasif 2 Intracapsular fractures Surgery should be done within 24 hours The risk of nonunion and avascular necrosis of the head increases after 2 days progressively F AO klasif 3 Garden classification F Garden klas 1 ch kosír 6 ch kpsír 5 ch kosír 4 M 66 y., intracapsular fx. Reduction in slight valgus Correct position of the screw Succesful healing with DHS ch kosír 3 ch kosír 2 ch burešová 8 ch burešová 7 ch burešová 6 ch burešová 5 F. 76 . Intracapsular fx of the neck, Garden IV. short lag screw of DHS thread in fracture line cut out phenomenon Thompson hemiarthroplasty ch burešová 4 ch burešová 3 F zdražil 3 F zdražil 2 F zdražil 1 M 73 y. Intracapsular fr., Garden IV. DHS with a short screw, thread in fracture line cut out phenomenon F krejcar 2 F krejcar 3 F krejcar 1 M 79 y. Intracapsular fx, cut out phenomenon of DHS indication for THR or hemiarthroplasty F drimlová 1 F drímalová 2 F 73 y. Intracapsular fx with varus dislocation Uncorrect reduction with DHS long thread of the lag screw in fracture line nonunion of the neck F drímalová 5 F drímalová 7 ch vacková 1 ch vacková 2 ch vacková 4 ch vacková 7 F 86 y, Subcapital fx Garden IV. Dislocation of Thompson prosthesis Revison with cemented THR F 57 y. Intracapsular fx Patient admited 48hours after injury Indication for THR F kalinová 1 F kalinová 2 Intracapsular fx, n= 142 - complications Cut out phenomenon (nonunion) 4 Fracture of DHS (nonunion) 3 Instability of DHS (nonunion) 6 Necrosis of femoral head 21 Causes of failure- intracapsular fx Uncorrect reduction (CCD angle and retroversion) Uncorrect insertion of screws in the head – neck region Short screws (TAD over 25 mm) F TAD 1 F AO klasif 3 Garden III.- retroversion Normal TAD index 10 mm F Garden klas 1 Causes of failure- intracapsular fx Wrong indication for DHS instead of THR in Garden III. fx. in patients over 65 y. Longer time of dislocation of the fx over 48 hours – head necrosis Underestimation of the stage of osteoporosis F krejcar 1 Vascularity of femoral head Disturbance of perfusion of the head by - dislocation of fragments - pressure of intracapsular hematoma - Assessment of vascularity by MRI Decompression: aspiration leading K- wire into the joint Internal fixation – within 24 hours After 48 hours higher risk of avascular necrosis Olšová 15 Management of femoral neck fractures Garden I. Conservative treatment If not succesful - arthroplasty F Garden klas 1 Garden II. Up to 70 y. DHS F Garden klas 1 Management of femoral neck fractures Garden III. Up to 65 y. DHS Over 65 y. arthroplasty Garden IV Up to 60-65 y. DHS Over 65 y. arthroplasty F Garden klas 1 F Garden klas 1 DHS Implant of choice in intracapsular fx stable pertrochateric fx 1-2 K wires in upper part of the neck intraoperatively to avoid twisting of the head DHS is preferable versus 3 screws F DHS 100 F DHS 2 K dráty THA výuka- CKP Hemiarthroplasty Cemented - uncemented Monoblock - modular type Unipolar - bipolar Metal head - ceramic head Over 80 y. Higher risk of acetabular errosions THR It is preferable versus hemiarthroplasty In dislocated fx over 65 y. In fractures with O.A. of the hip 3 - 5 % of dislocation 2 - 4 % of septic complication Reoperation rate in elderly: Internal fixation 40 % Arthroplasty 4,5 % Zl Trochanteric fractures F AO klasif 2 Occurs usually over 65 y. Often osteoporotic Significant comminuted fractures Low energy trauma Trochanteric fractures A1 stable F AO klas 5 A2 , A3 unstable ch večerová 4 ch večerová 3 ch večerová 2 ch večerová 1 F 69 y. Unstable pertrochanteric fx, 31A2 short lag screw failed OS with varus redislocation Thompson hemiarthroplasty ch svobodníková 4 F 65 y. Pertrochanteric fx, 31 A2 DHS in situ indication for PFN ch svobodníková 1 ch svobodníková 3 ch svobodníková 2 F 65 y. Fracture of the implant healed fx with a shortening ch svobodníková 6 ch trtílková 7 F 64 y Pertrochanteric fx, 31 A2 posterior position of the screw screw cut - out, varus collaps ch trtílková 6 ch trtílková 2 ch trtílková 1 ch trtílková 4 ch trtílková 5 F 64 y. Reosteosynthesis, good result with reconstruction nail ch lehárová 6 ch lehárová 4 ch lehárová 3 F. 60 y. Pertrochanteric fx with a subtrochanteric extension uncorrect reduction and OS succesful reosteosynthesis with reconstruction PFN ch lehárová 1 F 83 y. Comminuted trochanteric fx with severe osteoporosis, 31 A2 PFN osteosynthesis F koubová 1 F koubová 3 F koubová 4 F koubová 5 F koubová 6 F koubová 7 F 83 y. after 6 weeks redislocation in osteoporotic bone salvage with cemented THR ch dostal 3 ch dostal 2 ch dostal 1 M 58 y. Pertrochanteric fx Osteosynthesis with PFN nail proximal and posterior position of screws ch dostal 7 ch dostal 8 ch dostal 6 ch dostal 5 ch dosal 4 M 58 y. Reosteosynthesis Correct entry point of the screw Screw in the centre of the neck and head Healed fx F velkovová 3 F velkovová 2 F velkovová 1 F 64 y. Reverse comminuted 31A3 fx severe comminution, screw cut - out F velkovová 5 F velkovová 4 F 64 y. Healed with shortening, ossifications progresison of O.A. of the left hip joint Trochanteric fx, n= 342 - complications of PFN Uncorrect reduction 2 Short screws 3 Proximal placement of screws 2 Instability 3 Causes of failure in trochanteric fx Uncorrect reduction Short screws (index TAD over 25 mm) Uncorrect insertion of screws in the neck – head region Severe distraction of fragments F TAD 1 Normal TAD index 10 mm ch křivánková 1 Causes of failure in trochanteric fx Varus instability - comminution with posteromedial fragment Medial instability - comminution of lateral cortex Too early weight bearing Infection Underestimation of the stage of osteoporosis ch trtílková 6 Subtrochanteric fractures Intramedullary nails reconstruction nails or IMHS Proximal double screw locking mode Potential for dynamic gliding Stronger PFN in geriatric patients Cerclage wires THR- a salvage procedure F AO klasif 6 F AO klasif 6 ch petrlíková 3 ch petrlíková 2 ch petrlíková 1 F 68 y. Subtrochanteric fx with a large posteromedial fragment even in a case of osteoporosis we can achieve good result with correct reduction and stable internal fixation - reconstructive nail with cerclage wires F trbolová 2 F trbolová 1 F 66 y Subtrochanteric fx., O. A. of the left hip coxa vara after pertrochanteric fx. haeling with reconstructive nail indication for THR F trbolová 6 F trbolová 7 F trbolová 6 F trbolová 4 F 66 y. Healed subtrochanteric fx. coxa vara with O.A. of the left hip indication for THR F zlatkovská 1 F zlatkovská 6 F 65 y. Subtrochanteric fx, O.A. of the hip joint reconstruction nail F zlatkovská 7 F zlatkovská 11 F zlatkovská 9 F 65 y. Progression of O.A. Solved by cemented THR F zlatkovská 8 Management of trochanteric fractures In stable and unstable fractures – PFN Medin Advantage: - mininvasive procedure - one surgeon Dynamic distal fixation F PFN medin 2 Implants in osteoporotic bone F PFNA 1 PFN A Synthes Spiral blade in neck Impaction of trabecular porotic bone in subchondral region Augmentation with bone cement Implants in osteoporotic bone F PCCP 1 Gotfried PC.C.P Drilling with small diameter holes 2 compression screws Rotational stability Controled fracture impaction Indication: intracapsular neck fx stable pertrochanteric fx 2005-11-23 Conclusion Correct assessment of the fracture type Correct indication- OS or arthroplasty Choice of implant Correct reduction Correct position of the screws Stable fixation More complications come from uncorrect technique than from osteoporosis F ileová 1 Thank You for Your attention G Antares 1