Trochanteric fractures AO Trauma Basic Principles Course Learning

$Trochanteric fractures AO Trauma Basic Principles Course$

Trochanteric fractures AO Trauma Basic Principles Course

$Learning objectives • Describe the (biological) difference between intra- and extracapsular proximal femoral fractures$

Learning objectives • Describe the (biological) difference between intra- and extracapsular proximal femoral fractures • Describe the biomechanics of extracapsular fractures and the (resulting) choice of implant • Explain the rationale of intra- as opposed to extramedullary fixation • Describe the causes of failure concerning reduction and placement of implant

$Proximal femoral fractures differ… Intracapsular Extracapsular Result determined by biology: • Osteonecrosis Result determined$

Proximal femoral fractures differ… Intracapsular Extracapsular Result determined by biology: • Osteonecrosis Result determined by mechanics: • Varus deformation • Nonunion • Malunion • Arthritis • Medialization

$Trochanteric fractures—etiology Low-energy injury: • Usually elderly patients High-energy injury: • Usually younger patients$

Trochanteric fractures—etiology Low-energy injury: • Usually elderly patients High-energy injury: • Usually younger patients

$Trochanteric fractures: 31 A 1, 31 A 2, 31 A 3 and variants 31$

Trochanteric fractures: 31 A 1, 31 A 2, 31 A 3 and variants 31 A 1. 2 Pertrochanteric simple 31 A 1. 3 Pertrochanteric multifragmentary 31 A 3. 1 Intertrochanteric

What does the patient want? Treatment that enables the patient to return to, at least, pretrauma mobility as soon as possible

What does a doctor want for his/her patient ? • Early full weight bearing • Technically easy treatment

Treatment options • Nonoperative: • • About 14 weeks bed rest Virtually impossible for many reasons Secondary displacement obligatory Operative

Type of bone healing preferred: • Primary: • No means open, anatomical reduction • Secondary: • Given the biology, to be preferred

Implants available

Choice of implant • Rigid extramedullary fixation bears too high a risk for: • Early failure (cut-out) • More postoperative hip pain • Reduced postoperative mobility

Choice of implant • Insufficient evidence concerning locking plates • Full weight bearing postoperatively is questionable

Choice of implant • Replacement of (part of) the (essentially healthy) joint is not a first thought • Muscles attached to the greater trochanter then have to be reinserted = major functional loss

Operative treatment

$How to make a choice? Read the fracture “Stable” After reduction “Unstable” Still, after$

How to make a choice? Read the fracture “Stable” After reduction “Unstable” Still, after reduction

$How to make a choice? In a “stable” fracture (31 A 1) any (dynamic)$

How to make a choice? In a “stable” fracture (31 A 1) any (dynamic) device, extramedullary or intramedullary, will serve well

$How to reduce the fracture • Close reduction over fracture table: • Reducible and$

How to reduce the fracture • Close reduction over fracture table: • Reducible and stable • Reducible by other means and unstable • If no close reduction, then open reduction achieving anteromedial contact and fixation with the implant

$How to choose in an unstable fracture? Varus deformation Rotation Medialization shaft$

How to choose in an unstable fracture? Varus deformation Rotation Medialization shaft

Extramedullary implant Dynamic hip screw (DHS) DHS + trochanter stabilizing plate

Intramedullary implant

Extra- or intramedullary implant Extramedullary: Intramedullary • (Nearly) anatomical reconstruction • Nonanatomical reconstruction • Less strong implant • Semi-open procedure • Semi-closed procedure • Partial weight bearing • Direct full weight bearing

Evidence • Nail versus sliding hip screw—no difference: • Huang X, Leung F, Xiang Z, et al. Proximal femoral nail versus dynamic hip screw fixation for trochanteric fractures: a meta-analysis of randomized controlled trials. Scientific. World. Journal. 2013; 2013: 805805. • Matre K, Vinje T, Havelin LI, et al. TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. J Bone Joint Surg Am. 2013 Feb 6; 95(3): 200– 208.

Evidence slight change Intramedullary vs extramedullary: • …. tendency to better regain of mobility … with an intramedullary nail. . . (Parker [Injury. 2017; 48: 2762– 2767]) • …. supports the use of intramedullary nails for A 3 fractures (Bretherton et al [J Orthop Trauma. 2016 Dec; 30(12): 642– 646])

$Take-home messages • 31 A 1 (“stable”) fractures: • Any sliding device • 31$

Take-home messages • 31 A 1 (“stable”) fractures: • Any sliding device • 31 A 2 and 31 A 3 (“unstable”) fractures: • Intramedullary device • (Sliding hip screw with a lateral support device)