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2016 Annual Meeting
Instructional Course
Lecture Handout
Course Number: 250
Course Title: Femur Fractures: Subtrochanteric to Supracondylar
Location: Room W307C
Date & Start Time: Mar 2 2016 1:30 PM
INSTRUCTORS WHO CONTRIBUTED TO THIS HANDOUT:
Robert F Ostrum, MD Paul Tornetta III, MD
Philip R Wolinsky, MD
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AAOS – Femoral shaft fractures: Subtrochanteric to Supracondylar
ICL 250
IM Nailing of Subtrochanteric femur Fractures
Robert F. Ostrum, M.D.
University of North Carolina – Chapel Hill
• High compression/tension stress area with cantilever bend
• Deformity: flexion, external rotation, and abduction of the small proximal
fragment making IM nailing difficult
• Evaluation of fracture
o Piriformis fossa
o
Greater trochantero Lesser trochanter
• Surgical Planningo
Supine
o Lateralo
Fracture Table
• Implant Choiceso
Piriformis Nail
o Trochanteric Nail
• Problems
• Incorrect starting point
• Lack of reduction while reaming
•
Poor trajectory of guide rod
• IM nail with deformity
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Wrong Right
For IM nailing:
Reduction during reaming and the correct starting point are the keys to
optimal results
Operative tricks
• Use instruments, clamps to reduce flexion and abduction
deformities prior to reaming
• Start piriformis foss nail in line with shaft, guide pin NOT
pointing towards the lesser trochanter
• The trochanteric insertion site should be just MEDIAL to the
tip of the trochanter
• Skin incision for IM nailing is NOT at the tip of the trochanter
but rather 5-8 cms proximal and in line with the shaft
• MUST have a way to assess LENGTH and ROTATION
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References
1. Starr AJ, Hay MT, Reinert CM, Borer DS, Christensen KC.
Cephalomedullary nails in the treatment of high-energy proximal femur
fractures in young patients: a prospective, randomized comparison of
trochanteric versus piriformis fossa entry portal. J Orthop Trauma. 2006
Apr;20(4):240-6.
2. Perez EA, Jahangir AA, Mashru RP, Russell TA. Is there a gluteus
medius tendon injury during reaming through a modified medial trochanteric
portal? A cadaver study J Orthop Trauma. 2007 Oct;21(9):617-20.
3. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of theeccentric starting point for trochanteric intramedullary femoral nailing.
J Orthop Trauma. 2005 Nov-Dec;19(10):681-6.
4. French BG, Tornetta P 3rd. Use of an interlocked cephalomedullary nail
for subtrochanteric fracture stabilization. Clin Orthop Relat Res. 1998
Mar;(348):95-100.
5. McConnell T, Tornetta P 3rd, Benson E, Manuel J.
Gluteus medius tendon injury during reaming for gamma nail insertion. Clin
Orthop Relat Res. 2003 Feb;(407):199-202.
6. Streubel PN, Wong AH, Ricci WM, Gardner MJ.
Is there a standard trochanteric entry site for nailing of subtrochanteric femur
fractures. J Orthop Trauma. 2011 Apr;25(4):202-7.
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2
“A” Fractures•
Options
•
Nail
! Enough room for
locking screws
• Plate
! Fixed angle
“A” Fractures•
Options
•
Nail
! Enough room for
locking screws
• Plate
! Fixed angle
“A” Fractures•
Options
•
Nail
! Enough room for
locking screws
• Plate
! Fixed angle
“B” Fractures
•
Shear fractures
• Stabilize
! To the rest of the joint
! To the shaft
! Lag screws
! Buttress
! Antiglide
“B” Fracture Percutaneous ORIF
B Fracture “C” Fractures• Combination of “A” and “B”
• Principles:
! Restore joint …. C A
! Stabilize the metaphysis to theshaft
! Complexity of joint determines
options for stabilization
Simple Joint Injury
• Lag screws for the joint
•
Metaphysis
! Nail
! Plate
• Fixed angle
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3
Supracondylar Fractures• Short IM nails (GSH type)
• Compared to fixed angle:
! Equal to varus load
! to bending and torsion
• Failure mode: shaft fracture
through proximal screw hole
IM Nails• Advantages
! Midline incision
• Indirect reduction
•
Minimal stripping
• Blood loss
! Reaming distributes bone graft
! Metaphyseal comminution irrelevant
IM Nails• Disadvantages
! Intraarticular starting point
! Large intercondylar portal ?
! Locking screws may be through
coronal fracture lines
! Stress riser through unfilled
holes
Indications
• Metaphyseal injuries > 4 cmfrom notch (type A)
• Minimal intraarticular extension
• Large condylar fragments thatcan be fixed with lag screws(C1)
26 Year Old MVA S/P Nailing
Grade 3 Open C2 Fx Lag Screws + Nail Final
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Nonunion….BGTechnique• Midline incision
! Poke hole vs arthrotomy
• Reduce and lag intercondylarfracture first
• Indirect reduction of the
metaphysis
Technique• Radiolucent table
• Bolster
• Distractor ?
• Portal
• Direct up shaft on AP and lat
• Over-ream 1.5 mm
•
Lock at lesser trochanter
Incision Free Medial Side Arthrotomy
Portal Location
B l u m e n s t a t ’ s
T r o c h l e
a r G r o o
v e
Canal Location Nail Curvature
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5
Portal Location Portal Location
Even 1 mm
Proud is Bad!!
Flexion Arc
Avg arc 17°
34° - 51°
AP View AP View AP View
Physiologic
Valgus
Starter Reamer Distally Lock Check Length
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Proximal Locking• Level of the lesser trochanter
• Safest level
! Nerves cross
! Artery 1 cm medial
• Just at the piriformis
Example Nailed.. Too High!!
Watch Sagital AlignmentBlocking Screws
Blocking Reduction! Finals Results• Lucas 1993! 25 Fractures (9 open)
! Type A (6), type C (19)
! 6 Acute bone grafts
! Avg. ROM > 100°• 6 Required manipulation
! 1 Short, 1 12° varus
! 1 Late intraarticular infection
! Two iatrogenic fractures
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Results•
Iannacone 1994! 41 Fractures (22 open)
! Type A (19), type C (22)
! 80% Union by 4 months
! Delayed / non union due to injury
! Nail failure (6.4 screws in 11mm nail)
! 87% > 90° Motion
! All < 5° VV and < 10° AP angulation
Fractures Above TKA• Incidence 0.5% - 2.0%
• Bone quality
• Distal femoral notching
• Arthrofibrosis
Fractures Above TKA• Requires 12 mm intercondylarregion
• Contraindicated if closedintercondylar box
Technique
•
Midline incision
! Slightly larger than standard
• Obtain reduction
• Ream 1.5 mm over nail size
• Statically lock
• Postop early motion
74 Year Old Woman Treatment
Results
• Union in > 90%
• Time to union < 12 weeks
• Motion compared withpreinjury
Plates
• Indications
! Complex Intraarticular
! Below THA
! Low A type fractures
! Bowed femora
! Distal 1/3 fractures
“Old” Plate Case…
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8
Deformity Intraarticular Fragment Articular Reduction
Articular Reduction
AP VIEW
LATERAL VIEW
95°
Planned Axis
Affix to Screw Reduction Fluoro…
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10
6 Weeks 4 Months Complex Joint Injury• Joint has comminution
•
Posterior fragments
• Will not accept nail
! Hoop stresses
! Poor fixation of the locking
screws
Complex Joint Injury
• Plate is treatment ofchoice
• Fix joint (screws)
• Connect to shaft
• Fixed angle!!
! Prevents varus collapse
Problems..
• Locked plates:
! Fixed angle periarticular
segments
! Indirect reductions
! Biologically friendly
! Osteoporotic bone
• Different failure modes
Problems…
• Locked plates:
! Fixed angle periarticular
segments
! Indirect reductions
! Biologically friendly
! Osteoporotic bone
• Different failure modes
Problems
• Locked plates:
! Fixed angle periarticular
segments
! Indirect reductions
! Biologically friendly
! Osteoporotic bone
• Different failure modes
Old Ideas…New Tricks?
• How can we improve?
• Plate contours
• Hole configuration
• Screw direction
• Reduction techniques
• Instrumentation
When do we need them?• Periarticular fractures
! With metadiaphyseal
dissociation
•
Poor bone quality! Osteoporosis
! Nonunions
! Revision surgery
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11
Locked Plating…• Intraarticular fractures
• Joint fixation
! Outside plate
! Metadiaphyseal reduction
• Extraarticular fractures
• Around knee implants
Incision Deep Incision
VisualizationScrews Around Plate Lag Screw Position
Lag Screw Position Outrigger Metadiaphyseal Reduction
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Instrumentation• Simple
• Keep angles correct
• Appropriate guides
• Limit pieces
• Screw options…
Slide in Plate Provisionally Fix
Place Fixation Final AlignmentHealing is Good
• Grade 3A fx at 10weeks
• Good principles
• Indirect reduction
Worst Problems
Grade 3 open
Initial Treatment Delayed Fixation
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Delayed Grafting Delayed GraftingLateral Postop
5 Months… Periprosthetic Fractures Periprosthetic Fractures
Periprosthetic Fractures Periprosthetic Fractures Periprosthetic Fractures
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SMFA
0
5
10
15
20
25
30
35
40
45
3 Months 6 Months 12 Months
SOLVED So Far…• 143 Patients (target 160)! 75 Nails
! 68 Plates
• Adverse events
! 52 Total
! 25% for both nail and plate
! 20 Device related
Alignment
Valgus > 5° Varus > 5°
Nail 9 (12%) 0
Plate 14 (20%) 1 (2%)
Alignment
Valgus > 5° Varus > 5°
Nail 9 (12%) 0
Plate 14 (20%) 1 (2%)
ComplicationsNail Plate
Painful Implant2 Nail
8 Screws8 Plates(3 out)
Loose 3 2
Nonunion 0 2
Infection 2 1
Arthrofibrosis 0 1
Adverse Events• 5 DVT, 1 Death
• 20% Both groups
• Revision
! 5% Nails! 8% Plates
• Hardware removal! 15% Nails (90% screws)
! 10% Plates
Case Example Postop
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16
3 Weeks
Nail!!! Multitrauma..Open
14 Months, New Pain CT Intraop
Plate Final Summary• Nails…
! Metaphyseal comminution
! Long shaft extension
! Elderly patients
! Minimal intraarticular extension
• Large condylar fragments
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