Do we need a proximal femoral nail ? Mr Chris Oliver  DM, FRCS (Tr & Orth), FRCP, DMI RCSEd Consultant Orthopaedic Trauma ...
Edinburgh Orthopaedic Trauma Unit <ul><li>800,000 people local </li></ul><ul><li>tertiary referrals from 1.5 million </li>...
Modern hip nailing systems IMHS: 1990 Richards PFN:1995 Stratec Gamma: 1989 Howmedica
Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fra...
Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fra...
Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fra...
Implant-related fractures of the femur following hip fracture surgery <ul><li>Internal fixation or prosthetic replacement ...
Implant-related fractures of the femur following hip fracture surgery <ul><li>141patients sustained an ipsilateral fractur...
Implant-related fractures of the femur following hip fracture surgery <ul><li>The incidence # per 1000 person years  </li>...
Implant-related fractures of the femur following hip fracture surgery <ul><li>“ Implant-related fractures following hip fr...
Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail  - K Khan (data in press) <ul><li>Unit concept </li></ul><ul><li>“ Spa...
<ul><li>Initial cohort of 302 patients </li></ul><ul><ul><li>74 patients died (24.5% mortality at 1 year) </li></ul></ul><...
Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Union <ul><li>96.8% union at 6 months </li></ul><ul><li>7 patients: na...
Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Complications <ul><li>Lag screw failure - 12 patients </li></ul><ul><u...
Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Metaphyseal fracture <ul><li>Fracture distal to the tip of the nail (5...
Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Nail shape
 
 
 
Edinburgh Long Gamma Nail - Functional outcome <ul><li>Increased social dependence </li></ul><ul><li>209 patients living i...
Edinburgh Long Gamma Nail - Walking ability <ul><li>178 patients were initially independent ambulators </li></ul>
Edinburgh Long Gamma Nail - Walking aids <ul><li>158 initially walked without aids </li></ul>
Edinburgh Long Gamma Nail - Pain
<ul><li>Versatile treatment option for elderly population </li></ul><ul><li>“ Spans femur” but does have problems </li></u...
Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.  <ul>...
Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail.  <ul><li>46 consecu...
Do we need a proximal femoral nail ? <ul><li>In Edinburgh! </li></ul><ul><li>No type of PFN used. </li></ul><ul><li>Slidin...
Thank You
Upcoming SlideShare
Loading in...5
×

Do we need a proximal femoral nail ?

9,597

Published on

Do we need a proximal femoral nail ?

Published in: Health & Medicine
4 Comments
11 Likes
Statistics
Notes
  • i feel pfn is purely a market driven implant. Even RT nail is as good as pfn with less no of complications
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • PFN is purely a market driven implant
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Interesting subject. Do we need a proximal femoral nail ?. Question answered in this slide.

    Roy Jan
    http://au.freepolyphonicringtones.org/ http://at.freepolyphonicringtones.org/
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Great slideshow. I have taken a few of the structure graphics along with adapted to my startup
    Teisha
    http://dashinghealth.com http://healthimplants.com
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total Views
9,597
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
0
Comments
4
Likes
11
Embeds 0
No embeds

No notes for slide

Transcript of "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

×