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Intertrochanteris
- 1. AOTrauma Principles Course Intertrochanteric fractures Rogier Simmermacher, NL Denise Eygendaal, NL
- 2. Intertrochanteric fractures • Introduction • Treatment options • Choice of implant • Evidence • Conclusion
- 3. Introduction Intracapsular fractures • Treatment mechanically based • Result biologically determined Extracapsular fractures • Treatment mechanically based • Result mechanically determined
- 4. Anatomy
- 5. Anteversion
- 6. Etiology In the elderly In young people
- 7. Intertrochanteric fractures Risk factors in the elderly: • Less soft-tissue cover • Muscle weakness • Poor protective response • Impaired cognition/vision • Comorbidity/drugs
- 8. Impact • 17% will die within 6 months • 25% reduction in life expectancy • 50% new permanent deficits in activities of daily living • $ 81,300.- lifetime costs ($ 8,900 initially) • $ ????? savings due to fracture deaths
- 9. What does the patient want? Treatment that enables them to return to normal as soon as possible
- 10. Treatment options • Nonoperative: - ± 14 weeks bed rest - Virtually impossible - Secondary displacement obligatory • Operative
- 11. What does the doctor want? • Direct full weight bearing • A fracture implant assembly that withstands the loads • An easy and quick procedure • A forgiving implant
- 12. Fracture—implant assembly • Bone quality • Fragment geometry • Reduction • Implant • Implant placement
- 13. Bone—quality • Transition at IV / III • Patient-determined • Considerable variations
- 14. Fracture—geometry • Medial and posterior: - Portion are of importance • Trauma-determined • Need for classification
- 15. 31-A1
- 17. 31-A2
- 19. 31-A3
- 21. Fracture classifications—geometry • Müller AO Classification is suitable for group A1, A2, and A3 • Schipper, Acta Orthop Scand 2001 (72), 36–41 • Pervez, Injury 2002 (33), 71–75
- 22. Reduction • Critically important • To some degree surgeon’s choice
- 24. Implant placement • Depends on the type of implant • Depends on surgeon’s skills
- 25. Fracture—implant assembly • Bone quality • Fragment geometry • Reduction • Implant • Implant placement
- 27. Choice of implant • There is evidence that a rigid extramedullary fixation bears too high a risk for: - early failure (cut out) - more postoperative hip pain - reduced postoperative mobility
- 29. Choice of implant Read the fracture “stable” after reduction “unstable”
- 30. How to choose? • In a “stable” fracture (31-A1) any (dynamic) device extramedullary or intramedullary will serve well
- 31. How to choose in an unstable fracture? Varus deformation medialization shaft
- 32. Extramedullary implant DHS DHS + trochantor stabilizing plate
- 34. Extramedullary Intramedullary • Anatomical reconstruction (?) - Very stable reconstruction - Weak implant - Open procedure - No weight bearing • Nonanatomical reconstruction - Stable reconstruction - Strong implant - Semi-closed procedure - Direct full weight bearing
- 35. Evidence • Audige (2003) Int Orthop (27) meta-analysis PFN vs DHS/TSP - no difference • Nuber (2993) Unfallchirurg (106), n = 129 PFN vs DHS/TSP - no difference • Werner-Tutschku (2002) Unfallchirurg (105), n = 70 Cohort, PFN - 25.7% problems • Saudan (2002) Injury (33), n = 206 DHS vs PFN - no difference
- 36. Evidence • Harrington (2002) Injury (33) n = 60 DHS vs IMHS - no significant improvement • Parker Cochrane Database 2002 (04) n = 2472 - Extram. vs intram. - SHS is superior • Al-yassari (2002) Injury (33) n = 70 Cohort, PFN - 9% technical failures • Preite (2000) Chir Organi Mov (3) n = 147, 4 devices, - PFN adapts best
- 37. Summary • 31-A1 (“stable”) fractures might be treated with any sliding device • 31-A2 (“unstable“) fractures can be treated either with an intramedullary device which permits immediate full weight bearing or a sliding hip screw