clinical

1. Proximal femoral fractures
Evidence based approach
Mohamed Abulsoud (M.D)
Lecturer of orthopedic surgery
Faculty of medicine – Al-Azhar university
Cairo- Egypt

2. • ILO
• Decision making
• Preoperative planning
• Post operative Program
• Evidence based guidelines

3. Introduction
• Hip fractures comprise 20% of the operative
workload of an orthopedic trauma unit
• Singer BR et al. J Bone Joint Surg Br. 1998
• The mortality rate in the elderly patients
during the first year after hip fracture from
24% to 36%
• Vestergaard P. Osteoporos Int. 2007
• Proximal femoral fractures is a challenge
– Bone mass
– Blood supply
– Biomechanics
– Co morbidities

4. Introduction

5. Introduction

6. • Intertrochanteric femur
fractures account for 50%
of all proximal femur
fractures.
• Femoral neck fractures
account for 40%
• Bimodal age distribution
Introduction

7. • AO Fracture and Dislocation
Classification Compendium
2018
Classification

8. Classification

9. Classification

10. Classification

11. Lateral Wall thickness
• Using the traction
view with the leg in
neutral rotation
• Innominate tubercle
• 135°
• Should be >20.5 mm

13. Classification

14. Classification

15. Classification

16. Classification

17. Decision making

18. Decision making

19. Decision making

20. Decision making

21. 1: Use the Tip-to-Apex
Distance
2: ‘‘No Lateral Wall, No Hip
Screw’’

22. 3: Know the Unstable Intertrochanteric Fracture
Patterns, and Nail Them

23. 4: Beware of the Anterior Bow
of the Femoral Shaft
5: When Using a Trochanteric
Entry Nail, Start Slightly Medial
to the Exact Tip of the Greater
Trochanter

24. 6: Do Not Ream an Unreduced
Fracture.
7: Be Cautious About the Nail
Insertion Trajectory, and Do Not
Use a Hammer to Seat the Nail
8: Avoid Varus Angulation of the
Proximal Fragment—Use the
Relationship Between the Tip of
the Trochanter and the Center of
the Femoral Head

25. • 9: When Nailing, Lock the Nail Distally if the
Fracture Is Axially or Rotationally Unstable.
• Tip 10: Avoid Fracture Distraction When
Nailing

26. AAOS Guidelines
for Decision making
supports operative
• Moderate
fixation for
displaced)
evidence
patients
femoral
with stable (non-
neck fractures in
comparison with non operative treatment.
supports arthroplasty for
• Strong evidence
patients with unstable (displaced) femoral
neck fractures.

27. supports that the
• Moderate evidence
outcomes of unipolar and bipolar
hemiarthroplasty for unstable (displaced)
femoral neck fractures are similar.
• Moderate evidence supports a benefit to total
hip arthroplasty in properly selected patients
with unstable (displaced) femoral neck
fractures.
AAOS Guidelines
for Decision making

28. • Moderate evidence supports higher
dislocation rates with a posterior approach in
the treatment of displaced femoral neck
fractures with hip arthroplasty.
• Moderate evidence supports the preferential
use of cemented femoral stems in patients
undergoing arthroplasty for femoral neck
fractures.
AAOS Guidelines
for Decision making

29. • Moderate evidence supports the use of either a
sliding hip screw or a cephalomedullary device in
patients with stable intertrochanteric fractures.
• Strong evidence supports using a cephalomedullary
device for the treatment of patients with
subtrochanteric or reverse obliquity fractures.
cephalomedullary device for the treatment
• Moderate evidence supports using a
of
patients with unstable intertrochanteric fractures.
AAOS Guidelines
for Decision making

30. Preoperative evaluation
• Prior to an operation, the time that a surgeon devotes
to a careful preoperative plan is of critical importance
and often determines the success or failure of the
procedure
• The diagnosis alone is not enough to guide the
surgeon to the correct choice of a procedure.
• The surgeon must have a thorough knowledge of the
relevant operative procedures and the relative
dangers and success rates of each.

31. Detailed history
careful physical examination
Laboratory tests
Appropriate x-rays
Other imaging studies, CT scans, 3-D
reconstructions, or MRI.
Preoperative planning

32. History
• Deep vein thrombosis/pulmonary embolism(DVT/PE).
• Medications(Anticoagulation-Bisphosphonate-
Steroids…..).
• Immune deficiency (DM).
• Malabsorption diseases
• Angina or CVA, aortic stenosis,
• Active infection (pulmonary or genitourinary)
• Cognitive disorders (Delirium)
AMPLE

33. Examination
• Associated Injuries
• Low-energy fractures, associated injuries are most
commonly fractures of the distal radius or proximal
humerus, and minor head injuries.
• High-energy fractures are more commonly
associated with ipsilateral extremity trauma, head
injury, and pelvic fractures.
• Soft tissue condition
• Neurovascular state

34. Lab
• Calcium, phosphate, and alkaline phosphatase
• A complete blood count (CBC)
• 25-hydroxy vitamin D
• Thyroid stimulating hormone (TSH)
• parathyroid hormone (PTH )
• Protein, Albumin
• kidney function tests
• Liver function test
• Coagulation profile
• Others…….

35. • Foster et al. reported a 70% mortality for
patients
compared
with a
to a
serum albumin <3gm%
mortality rate of 18% in
patients with an albumin level ≥3gm% .
Lab

36. Radiographs should include
• an anteroposterior (AP) view of the pelvis,
• A full length AP and lateral films of the femur
• Traction views.
Radiography

37. Radiography

38. Radiography

39. Radiography

40. Radiography

41. Radiography

42. Radiography

43. • Traction film
Radiography

44. Radiography

45. AAOS Guidelines
for preoperative practice
• Moderate evidence supports MRI as the
advanced imaging of choice for diagnosis of
presumed hip fracture not apparent on initial
radiographs.
• Due to the quality of existing literature, as well as potential
harm with radiation exposure related to use of CT in this
setting, this modality was not recommended for evaluation of
occult hip fracture

46. • Strong evidence supports regional analgesia to
improve preoperative pain control in patients
with hip fracture.
• Moderate evidence does not support routine
use of preoperative traction for patients with
a hip fracture.
AAOS Guidelines
for preoperative practice

47. • Moderate evidence supports that hip fracture
surgery within 48 hours of admission is
associated with better outcomes.
• Limited evidence supports not delaying hip
fracture surgery for patients on aspirin and/or
clopidogrel. (no regional anaesthesia)
AAOS Guidelines
for preoperative practice

48. • Preoperative Planning Checklist
• Traction OR table C-arm compatible with optional foot or
skeletal traction
•Fluoroscopy C-arm opposite surgeon with ability to rotate over
and under
• Equipment: Soft tissue retractors, Schanz pins for joysticks,
elevators, bone hook, large bone forceps, 3.2-mm K-wires for
provisional stabilization, power drivers
• Implant system with complete inventory of sizes
• Backup plan for alternative internal fixation choice
Planning

49. Planning

50. Planning

51. Planning

52. Postoperative program
VTE prophylaxis
Blood transfusion
Rehabilitation
Medications
Weight bearing

53. • Moderate evidence supports use of venous
thromboembolism prophylaxis (VTE) in hip
fracture patients.
AAOS Guidelines
for Postoperative practice

54. Antithrombotic agents
• Antiplatelet drugs
• Acetylsalicylic acid (Aspirin®)
• Thienopyridines: clopidogrel (Plavix®)
• Anticoagulants
• Vitamin K antagonists (VKAs): coumarins (Warfarin®,
Marcumar®, ……)
• Unfractionated heparin (UFH)
• Low-molecular-weight heparins (LMWH) :enoxaparin
(Lovenox®)
• Synthetic Factor Xa inhibitor: fondaparinux (Arixtra®)

55. Thromboprophylaxis
• LMWH, enoxaparin: 40 mg S/C once or 30 mg
S/C twice daily
• Fondaparinux: 2.5 mg S/C once daily
• Rivaroxaban 10 mg oral once daily
• Vitamin K antagonists dosed to a target value
of INR 2.5
• low-dose UFH 5000 IU S/C twice daily

56. • In patients undergoing hip fracture surgery
(HFS), we recommend use of one of the
following rather than no antithrombotic
prophylaxis for a minimum of 10 to 14 days:
LMWH, fondaparinux, LDUH, adjusted-dose
VKA, aspirin (all Grade 1B) , or an IPCD (Grade
1C)

57. • In patients undergoing HFS, we suggest the
use of LMWH in preference to the other
agents we have recommended as alternatives.

58. • For patients undergoing HFS and receiving
LMWH as thromboprophylaxis,
we recommend starting either 12 h or more
preoperatively or 12 h or more postoperatively
(Grade 1B) .

59. • In patients undergoing HFS, we suggest using
dual prophylaxis with an antithrombotic agent
and an IPCD during the hospital stay (Grade
2C)

60. • In patients undergoing HFS and increased risk
of bleeding, we suggest using an IPCD or no
prophylaxis rather than pharmacologic
treatment (Grade 2C)

61. • For asymptomatic patients following HFS,
we recommend against Doppler (or duplex)
ultrasound screening before hospital discharge
(Grade 1B)

62. • Strong evidence supports a blood transfusion
threshold of no higher than 8g/dl in
asymptomatic postoperative hip fracture
patients.
AAOS Guidelines
for Postoperative practice

63. • Moderate evidence supports that supervised
occupational and physical therapy across the
continuum of care, including home, improves
functional outcomes and fall prevention.
• Strong evidence supports intensive physical
therapy post-discharge to improve functional
outcomes in hip fracture patients.
AAOS Guidelines
for Postoperative practice

64. that
• Moderate
postoperative
evidence supports
nutritional supplementation
reduces mortality and improves nutritional
status in hip fracture patients.
• Moderate evidence supports
supplemental vitamin D and
use of
calcium in
patients following hip fracture surgery.
AAOS Guidelines
for Postoperative practice

65. • Moderate evidence supports that patients be
evaluated and treated for osteoporosis after
sustaining a hip fracture.
• Limited evidence supports preoperative
assessment of serum levels of albumin and
creatinine for risk assessment of hip fracture
patients.
AAOS Guidelines
for Postoperative practice

66. The stability scoring System
Of IMN in trochanteric fr

67. Maintenance of the
fracture reduction by
the stable fixation in
the patient scores over
5 could be predicted by
the postoperative
radiograms
Lee et al 2013
The stability scoring System
Of IMN in trochanteric fr

68. The stability scoring System
Of IMN in trochanteric fr