Do we need a proximal femoral nail ?

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Do we need a proximal femoral nail ?

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  • i feel pfn is purely a market driven implant. Even RT nail is as good as pfn with less no of complications
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  • PFN is purely a market driven implant
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  • Interesting subject. Do we need a proximal femoral nail ?. Question answered in this slide.

    Roy Jan
    http://au.freepolyphonicringtones.org/ http://at.freepolyphonicringtones.org/
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  • Great slideshow. I have taken a few of the structure graphics along with adapted to my startup
    Teisha
    http://dashinghealth.com http://healthimplants.com
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Do we need a proximal femoral nail ?

  1. 1. Do we need a proximal femoral nail ? Mr Chris Oliver DM, FRCS (Tr & Orth), FRCP, DMI RCSEd Consultant Orthopaedic Trauma Surgeon Edinburgh Orthopaedic Trauma Unit Edinburgh, Scotland
  2. 2. Edinburgh Orthopaedic Trauma Unit <ul><li>800,000 people local </li></ul><ul><li>tertiary referrals from 1.5 million </li></ul><ul><li>5500+ operations per year </li></ul><ul><li>45,000+ out-patients per year </li></ul><ul><li>50% of unit workload concerns orthogeriatric fractures </li></ul><ul><li>1000+ proximal femur fractures per year </li></ul><ul><li>PFN last year - zero! </li></ul>
  3. 3. Modern hip nailing systems IMHS: 1990 Richards PFN:1995 Stratec Gamma: 1989 Howmedica
  4. 4. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur <ul><li>Prospective, randomised controlled clinical trial with observer blinding. </li></ul><ul><li>400 consecutive patients 399 followed-up to one year or death. </li></ul><ul><li>Short-type Gamma nail (203 patients) or Richard's SHS (197 patients). </li></ul><ul><li>Outcome measurements were fixation failure and reoperation. </li></ul><ul><li>Functional outcome; pain, mobility status, range of movement were assessed until one year. </li></ul><ul><li>Adams CI, Robinson CM, Court-Brown CM, McQueen MM.  </li></ul><ul><li>J Orthop Trauma. 2001 Aug;15(6):394-400. </li></ul>
  5. 5. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur <ul><li>Revision Gamma nail group 6%, Richard's group 4% p = 0.29 </li></ul><ul><li>One subcapital femoral fracture in the Richard's group. </li></ul><ul><li>Femoral shaft fractures Gamma nail group (2%) none in the Richard's group (p = 0.13). Three required revision to another implant. </li></ul><ul><li>Lag-screw cut-out Gamma nail group (4%) Richard's group (2%) p = 0.37 </li></ul><ul><li>Postoperative complications - same. </li></ul><ul><li>No difference functional status at one year. </li></ul><ul><li>Adams CI, Robinson CM, Court-Brown CM, McQueen MM.  </li></ul><ul><li>J Orthop Trauma. 2001 Aug;15(6):394-400. </li></ul>
  6. 6. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur <ul><li>“ The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications”. </li></ul><ul><li>“ Routine use of the Gamma nail cannot be recommended over the current standard treatment of dynamic hip screw and plate”. </li></ul><ul><li>Adams CI, Robinson CM, Court-Brown CM, McQueen MM.  </li></ul><ul><li>J Orthop Trauma. 2001 Aug;15(6):394-400. </li></ul>
  7. 7. Implant-related fractures of the femur following hip fracture surgery <ul><li>Internal fixation or prosthetic replacement of the femoral head increases the risk of a later femoral fracture in susceptible osteoporotic patients. </li></ul><ul><li>Analyze the incidence of and risk factors for implant-related fractures of the femur after previous hip fracture surgery. </li></ul><ul><li>January 1988 to December 1997, 6230 patients (median age, eighty-two years; male: female ratio, 1247:4983) who sustained a total of 6696 hip fractures </li></ul><ul><li>Prospective study </li></ul><ul><li>Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J. </li></ul><ul><li>J Orthop Trauma. 2001 Aug;15(6):394-400 </li></ul>
  8. 8. Implant-related fractures of the femur following hip fracture surgery <ul><li>141patients sustained an ipsilateral fracture of the femur at a median of twenty-four weeks following the original hip fracture surgery. </li></ul><ul><li>Survivorship analysis of the hip fracture population revealed an overall rate of subsequent femoral fracture of 2.9% at five years, which increased to 5.1% at ten years. </li></ul><ul><li>2/3 fractures propagated from tip of the implant. </li></ul><ul><li>Analysis of the subsequent fractures according to the type of implant used to treat the original fracture revealed considerable differences in incidence. </li></ul><ul><li>Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J. </li></ul><ul><li>J Orthop Trauma. 2001 Aug;15(6):394-400 </li></ul>
  9. 9. Implant-related fractures of the femur following hip fracture surgery <ul><li>The incidence # per 1000 person years </li></ul><ul><li>Gamma nail 18.74 </li></ul><ul><li>Cementless hemiarthroplasty 11.72 </li></ul><ul><li>Compression hip screw 4.46 </li></ul><ul><li>Cannulated screws 4.50 </li></ul><ul><li>Primary arthroplasty with cement 6.2 </li></ul><ul><li>Arthroplasty with cement as a revision procedure following failure of a primary implant 22.39 </li></ul><ul><li>Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J. </li></ul><ul><li>J Orthop Trauma. 2001 Aug;15(6):394-400 </li></ul>
  10. 10. Implant-related fractures of the femur following hip fracture surgery <ul><li>“ Implant-related fractures following hip fracture surgery are more common than has previously been appreciated”. </li></ul><ul><li>“ Risk of later ipsilateral femoral fracture is increased by the use of a Gamma nail or a cementless hemiarthroplasty to treat the original hip fracture”. </li></ul><ul><li>Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J. </li></ul><ul><li>J Orthop Trauma. 2001 Aug;15(6):394-400 </li></ul>
  11. 11. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail - K Khan (data in press) <ul><li>Unit concept </li></ul><ul><li>“ Span the femur and prevent periprosthetic fractures” </li></ul><ul><li>Prospective study </li></ul><ul><li>Mortality, functional outcome and complications </li></ul><ul><li>302 patients February 1994 to December 2001 (median age 78.5 ) </li></ul><ul><li>Inclusion </li></ul><ul><li>Subtrochanteric fracture </li></ul><ul><li>Low-energy trauma (fall from standing height or below) </li></ul><ul><li>Exclusion criteria </li></ul><ul><li>High-energy injuries </li></ul><ul><li>Pathological fractures due to metastatic tumour </li></ul>
  12. 12. <ul><li>Initial cohort of 302 patients </li></ul><ul><ul><li>74 patients died (24.5% mortality at 1 year) </li></ul></ul><ul><ul><li>10 patients: untraceable </li></ul></ul><ul><ul><li>7 patients: refused to participate </li></ul></ul><ul><li>211 patients: Follow-up to 1 year </li></ul><ul><li>Peri-operative complications: 70 patients (23.2%) </li></ul><ul><ul><li>43 (14.2%) treated non-operatively </li></ul></ul><ul><ul><li>27 (8.9%) required further surgery </li></ul></ul><ul><ul><li>18 required revision of the nail </li></ul></ul><ul><li>Survivorship analysis Long Gamma Nail revised in 7.1% </li></ul>Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail
  13. 13. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Union <ul><li>96.8% union at 6 months </li></ul><ul><li>7 patients: nail removed for suspected non-union </li></ul><ul><ul><li>3 fractures: united, no further action </li></ul></ul><ul><ul><li>4 fractures: non-union confirmed, nail revised </li></ul></ul><ul><li>Nail breakage (1 patient): non-union </li></ul>
  14. 14. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Complications <ul><li>Lag screw failure - 12 patients </li></ul><ul><ul><li>Lag screw cut-out (9) </li></ul></ul><ul><ul><li>Lag screw penetration into acetabulum (1) </li></ul></ul><ul><ul><li>Lag screw back out (2) </li></ul></ul><ul><li>AVN of femoral head (without cut-out) </li></ul><ul><ul><li>Revised to long stem cemented THR </li></ul></ul>
  15. 15. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Metaphyseal fracture <ul><li>Fracture distal to the tip of the nail (5) </li></ul><ul><ul><li>All elderly females - Osteoporosis </li></ul></ul><ul><ul><li>Marked bowing of femur </li></ul></ul><ul><ul><li>Nail abutting anterior cortex (x-ray) </li></ul></ul><ul><ul><li>Exchange nail (modified) & cerclage wire </li></ul></ul><ul><li>Protrusion of nail tip through anterior cortex during insertion (2 cases) </li></ul>
  16. 16. Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Nail shape
  17. 20. Edinburgh Long Gamma Nail - Functional outcome <ul><li>Increased social dependence </li></ul><ul><li>209 patients living in their own home prior to injury </li></ul>
  18. 21. Edinburgh Long Gamma Nail - Walking ability <ul><li>178 patients were initially independent ambulators </li></ul>
  19. 22. Edinburgh Long Gamma Nail - Walking aids <ul><li>158 initially walked without aids </li></ul>
  20. 23. Edinburgh Long Gamma Nail - Pain
  21. 24. <ul><li>Versatile treatment option for elderly population </li></ul><ul><li>“ Spans femur” but does have problems </li></ul><ul><li>Acceptable rate of complications </li></ul><ul><li>Satisfactory functional outcome considering pre-morbid status </li></ul><ul><li>Now using Gamma 3 </li></ul>Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail
  22. 25. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures. <ul><li>Meta-analysis eighteen trials comparing the Gamma nail with the SHS were included, with data available for 2575 patients. </li></ul><ul><li>“ Given the lower complication rate of the SHS in comparison with Intramedullary nails, it appears that the SHS is superior for trochanteric fractures” </li></ul><ul><li>“ Further studies, reversed fracture lines and subtrochanteric fractures” . </li></ul><ul><li>Parker MJ, Handoll HH </li></ul><ul><li>Cochrane Database Syst Rev. 2004;(1):CD000093. </li></ul>
  23. 26. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. <ul><li>46 consecutive patients (47 fractures) </li></ul><ul><li>Average age 76.4 years </li></ul><ul><li>74.5% # unstable </li></ul><ul><li>re-operation rate was 19.1% </li></ul><ul><li>“ PFN is a suitable implant for unstable fractures, but the high re-operation rate precludes its routine use for every pertrochanteric fracture”. </li></ul><ul><li>Fogagnolo F, Kfuri M Jr, Paccola CA </li></ul><ul><li>Arch Orthop Trauma Surg. 2004 Jan;124(1):31-7. Epub 2003 Sep 11. </li></ul>
  24. 27. Do we need a proximal femoral nail ? <ul><li>In Edinburgh! </li></ul><ul><li>No type of PFN used. </li></ul><ul><li>Sliding Hip Screw (DHS) used as preferred implant for intertrochanteric fractures. </li></ul><ul><li>If there is a subtrochanteric fracture we prefer to nail and “span the whole femur”. </li></ul><ul><li>Avoid totally the “tip fracture” </li></ul><ul><li>If patient over 55 with a femoral shaft fractures we use a reconstruction cephallomedullary nail. </li></ul><ul><li>Technology is still evolving. </li></ul>
  25. 28. Thank You

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