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Fracture intertrochanter femur dr.sandeep agrawal agrasen hospital gondia india

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Fracture Intertrochanter femur ( Hip ) ,Dr.Sandeep Agrawal,Agrasen Hospital,Gondia,Maharashtra,INDIA.
DHS, PFN, Lateral wall shatter,osteoporosis,unstable Reverse Oblique Fracture,Z effect,Classification,Trochanter stabilising plate TSP,Cement or Bone Matrix Augmentation,Total hip replacement or Bipolar Prosthesis,LCP Proximal Femur,www.agrasenortho.com,drsandeep123@gmail.com
Fracture Intertrochanter femur,Neck Femur Fracture,Osteoporosis,BMD,Vitamin D3,Calcium Deficiency,Osteomalacia,Bisphosphonates,PFN Nail,TAD,DHS Plate,DCS,Proximal Femur LCP,TSP Plate,Bipolar Prosthesis,THR

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Fracture intertrochanter femur dr.sandeep agrawal agrasen hospital gondia india

  1. 1. I‘Il’2l('llli‘i“ IllIi’I'll‘iIi‘Il£l| lli‘| ‘ I‘Il‘ilI1ll‘ . . l)i‘. .'; iiirl«~<‘[> ; _i'i': i: il I5.I}l§llI'llii>}): li‘<lli' ; ;'i‘: xsi*ii Iliixlllllil 5 “J (Lniiiliu I£lII£ll'£l. ~»Illl‘. ‘I linliu . ilrsziililwilill? “:>’iIi; iil. i‘niii
  2. 2. Intertrochanteric Hip Fracture Objectives | m.: (|(. m., . rI‘l‘(‘1tIIli(‘III ()| )II()ll>§ lN_| mmm] ”| - lnlium Il‘{‘£lI| ll(‘llI Ii'(‘IllII(| l|(‘. ‘ . .. . (1 '. ,. ' . l’li. s'i(*ul liimliiiqs‘ MHPIH ”m"' 1 l . ‘V -I)2t' . ‘. '(‘. s'. '| ]l(’llI ”l”m" 5 (iI2l. '. s'lII(‘2iII()II S(‘Il(‘lIi(‘ | ““”| ”"(‘ HI | H“‘m'H"'I hzi| ag<- I)l'()(‘(‘(Illl’(‘. rI‘| ‘(‘2lIlll(‘l]I (mills Dr. Sandeep AgraWaI, Agrasen H0spitaI, G0ndia INDIA l
  3. 3. Preface « lntertrochanteric fracture (vs femoral neck fracture): more advanced age poor prefracture ambulatory ability more medical problems more osteoporotic more previous osteoporosis-related fI'aC’[uI'e(vertebra| compression, proximal humerus, distal radius fracture) l I_)i'. Samlcc| ) gi'aziI. ~gi'asci1 I Iospilzil, (.; 'om. Iia Ih DI A l. ..S. .-. .i. __. ,_. .-_. _. _-. -__. S_. . __. .S, . _-. ._. __ __. -____. .___. ..
  4. 4. Mechanism of Injury - Hip fracture in young adults: high energy trauma, must check associated injuries - Hip fx in elderly: 90% result from a simple fall - Tendency to fall: poor vision, xlzmuscle power, labile BP, sl/ reflexes, vascular disease, coexisting musculoskeletal pathology I, )l'. S£lIl(I(. ‘C| ) ". g'l‘£tilI. ’gl'2lS(. ‘II IIospilz1l. (}(_m(| ia INDI ‘ i >— _. . _ . ... ... ... .. .2 . . _ M . :.c_ . _ _ . _ . - . _J
  5. 5. I, )l'. S£lIl(. I(. ‘(‘j) : —gi'az1I. 'gl'2lS(. ‘II IIospilal. (}(_m(| ia INDI ‘ Mechanism of Injury - Cummings & Nevitt (1994): 4 factors determine falls resulting hip fracture: 1.fal| s: lands on or near hip 2.inadequate protective reflexes 3.inadequate local shock absorbers (muscle & fat) 4.insufficient bone strength
  6. 6. The hip protector In the elderly, it is more common to fall sideways onto the hip rather than forwards onto hands or knees as with younger people. The direct impact of a sideways fall is on the greater trochanter of the proximal femur, which can result in hip fracture. There has, therefore, been interest in finding a device that can protect the hips and prevent fracture, to allow the force and energy of a fall to be attenuated and shunted away from the greater trochanter. One such device is the external hip protector, which has been found to reduce the risk of hip fracture by up to 80% in those at increased risk for hip fracture, when it is being worn at the time of the fall. There is, however, poor compliance with wearing hip protectors owing to discomfort and impracticality, and they are usually not worn at night. Compliance difficulties may be reduced through the use of education programs. Anterior view Antevolamnl view I«: 2:: -:v; r;» lat L'L‘: ‘. ‘rrrmal hcsd rzrcarcr irr(I'ar 'r' T-rrnnyzl shal-
  7. 7. Signs & Symptoms - Displaced fracture: pain, can’t stand - Non-displaced or impacted fracture: may be ambulatory, minimal pain (thigh/ groin) - Stress fracture of hip: trauma(-), ask for recent changes in type, duration, frequency of physical activities - Pathological fracture I)l'. Sall(lccp ". g'l‘£tilI. 'gl'2lS(. ‘II IIospilal. (}oll(| ia INDI ‘ i >— _. . _ . ... ... ... .. .2 . . _ M . :.c_ . _ _ . _ . - . _J
  8. 8. Physical Examination: 1 Displaced fracture: shortened & external rotated leg 1 Tenderness/ ecchymosis 1 Avoid Range of motion test I, )I'. S£tIl(. ICC| ) gl'aziI. ~gl'ascl1 IIospilal, (.}om. Iia Ih DI A l. ._S. -.. i. . _._. _. __. ,_. .-_. - ___ __ _ _ - _ S _ _ . _ T l
  9. 9. EXAMINATION i> Auscultation Lippmann test sensitive for detection of occult fractures of the proximal femur or pelvis 2> Bell of the stethoscope on symphysis pubis and tapping on the patella of both extremities variation in sound conduction determines discontinuity i> Decreased tone or pitch — fracture Dr. Sandeep . AgrawaP, Agraser1 Hospital, Gondia INDIA -J
  10. 10. Images Standard X-ray exams: PdWsAP , , W AP & cross-table lateral view of - involved hip Femur internal rotation 10~15 degrees offset femoral neck s. -.. anteversion -) true AP of proximal femur A _, “Ci _. __ __ . ..__-_ _-. .. _. __. ,___. __a. _.__7 I, )I'. S2tIl(. IC(‘| ) gl'aaI. ~g‘l'ascl1 I Iospilal, (.; 'om. Iia Ih DI A
  11. 11. Femoral Neck Lateral Procction Hip cross table lateral projection
  12. 12. IMAGING STUDIES — XRAYS t> Pelvis with both hips — AP, xray of the affected hip — AP and cross-table lateral fi> Traction films (with internal rotation) helpful in communited and high-energy fractures and in determining implant selection i> Subtrochanterie extension Femur AP and lateral Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA
  13. 13. OTHER IMAGING STUDIES 9 Magnetic Resonance Imaging MRI) currently the imaging study of choice in delineating non-displaced or occult fractures that may not be apparent on plain radiographs Preferred over CT due to higher sensitivity and specificity for a more rapid decision process : > Bone scans or CT reserved for those who have contradictions to MRI. Technetium bone scans 9 Technetium bone scan when a hip fracture is suspected but not apparent to standard radiographs requires 2-3 days to become positive Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA
  14. 14. Applied Anatomy - lntertrochanteric region: dense trabecular bone, transmit and distribute stress a/ s u _ 0 re cornpress Iraoeculao: -, the rt. -nsron I C a | Ca r fe rn O ra | e - II. 'mer: ul. -re my well vrsrble . 1.vertica| wall of dense bone 2.posteromedia| aspect of femoral shaft 9 posterior portion of femoral neck , ;,. -.. -;_—; . 3.interna| trabecular strut within ' '}” ' '1 inferior portion of femoral neck j I, )l'. S£lIl(, ICC| .) Agl'aaI. ~gl'ascll IIospilal. (}on(Iia IA DI A j
  15. 15. Biomechanics Fracture involve cortical bone and compact cancellous bone, nonhomogeneous structure 1 Fracture occur along path of least resistance ~ Amount of energy absorbed by bone 9 simple comminuted fracture I, )I'. S£tIl(. IC(‘| ) Agraual. Agrascli IIospilaI, Gon(. Iia IA D . .__. -__-_. __, ._. -7
  16. 16. Biomechanics 1 During gait: body weight9 bending moment 9 sup. cortex of femoral neck 1 Gluteus medius contraction 9 axial compression stress/ strain in femoral neck9counterba| ance 1 Continuous strenuous activity 9 muscle fatigue 9 stress fx . .i-. ..--. ... -.. . _ _. .. - . ... _.-. ..-_-. -.. ... ._. .-. .-_-. ... __. ... .._. ._. .,M__, __, I) I, )I'. S£tIl(. IC(‘| ) AgraaI. Agrascn I IospilaI, (.; 'on(. Iia IA DI A
  17. 17. Treatment Options: nonoperative 1 < 19603, no suitable fixation device: traction+pro| onged bed rest9bone healing (10~12weeks)9 ambulation training . ... ... ... .. high complication rates 1 Bed sores, UTI, pneumonia, joint contracture, thromboembolic complications . ... . . .high mortality rate I, )I'. S£tIl(. ICC| ) Agrzmal. Agrascli IIospilaI, (.}on(. Iia IA DI A l. ..S. --i . _- . -_. _. , ___ __ _ _ -_ S _ _. _ l
  18. 18. Evaluations of OP Techniques 1 Ender nail: retrograde insertion from distal femur no fracture exposure, less blood loss, less operative time, soft tissue compromise Malrotation, supracondylar femur fx, proximal migration through femoral head, nail back-out & knee pain I, )I'. S£tIl(. IC(‘| ,) Agraual. ~gl'ascl1 IIospilaI, (.}on(. Iia IA DI A l. ..S. -.. ,. . .._. __. __. ,__- S ___ _ - , S _ _ . _ l
  19. 19. Nonoperative : 1 Insufficient traction9 hip varus deformity & leg shortening 1 > 19603 Internal fixation: early immobilization Now, nonoperative treatment indications: elderly patient with poor medical condition nonambulatory patient with minimal discomfort I) I, )I'. S£tIl(. ICC| ) Agrzmal. Agrascli IIospilaI, (.}on(. Iia IA DI A
  20. 20. TREATMENT OPTIONS 4 NON OPERATIVE 9 Bucl<’s traction or extension 9 Russell skeletal traction 9 Balanced traction in Thomas splint 9 Plaster spica immobilization 9 Derotation boot Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA j
  21. 21. HISTORY 9 jewett in I930 introduced the Jewett nail to provide immediate stal)iIity of fracture fragments and early mobilization of the patient 9 I950 Earnest Roll in Germany first to use sliding screw and Pugh and Badgley introduced sliding nail with trephinc tip in USA. 9 I962 —- Massie - modified sliding devices i. o allow collapse an(l impaction ofthe fragments. Richard rnanul‘"acturing co. ofl'SA produced Dynamic Hip Screw 9 I966 — Kuntschner and later in 1970 Enders introduced the coridyloceplialic intramedullar'y devices 9 I984 Russel Taylor reconstructed i11t1'a1r1c(l11llarj' nail for pcrtroehantcric and subtrochanteric fractures 9 I992 —— Halder and Williams introduced the Garnma nail Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA
  22. 22. Evaluations of OP Techniques Controlled fracture impaction -9 sliding nail-plate devices, nail telescope in a barrel Sliding hip screw devices i Bidirectional sliding: Medoff plate - Variations on the sliding hip screw's basic design include the variable angle hip screw (VHS) , Talon compression hip screw, greater trochanteric stabilizing plates, the Medoff plate, and the percutaneous compression plate (PCCP). . . 4>)~ . .___-_ _-. .. . . _. .-__- . __4._, -7 l_)i'. San(| ccp gi'aa| . ~gi'asci1 I | os| )ila| ,(; '()ii(| ia IR DI R
  23. 23. The Medoff plate- biaxial sliding hip screw - It has a standard lag screw component for compression along the femoral neck. In place of the standard femoral sideplate, however, it utilizes a coupled pair of sliding components that enable the fracture to impact parallel to the longitudinal axis of the femur. - A locking set screw may be used to prevent independent sliding of the lag screw within the plate barrel; if the locking set screw is applied, the plate can only slide axially on the femoral shaft (uniaxial dynamization). If, however, the surgeon applies the implant without placement of the locking set screw, sliding may occur along both the femoral neck and the femoral shaft (biaxial dynamization). For most intertrochanteric fractures, biaxial dynamization is suggested. i D| '.San(| eep gi'ua| Agi'asci1 | |ospila| ,Goi1<Jia IRDI N l __ W, _______________________ _.
  24. 24. Percutanious compression plate Two lag screws these two lag screw components provide greater rotational stability of the proximal fracture fragment. Barrel component Use of the PCCP was associated with shorter operative times, less blood loss, and need for fewer number of blood transfusions. No differences were found with respect to fracture union or functional outcomes, a learning curve exists with large variations in operative time compared with a standard sliding hip screw.
  25. 25. CLASSIFICATION 1.None . ... widely accepted 3.Unstable: Posteromedial fragment Lateral wall shatter Reverse obliquity Subtrochanteric extension Osteoporosis I D| '.Saii(| eep Agi'zla| .Agi'asci1 | |ospilal, Goi1<Jia INDI A E l __ t_ M , _____ ___. _. 2.Stability: stable or unstable I I
  26. 26. DIAGNOSIS AND CLASSIFICATION 5> lncrease(l surgical complexity and recovery are associated with UNSTABLE FRACTURE PATTERNS: - Posteromedial large separate fragmentatioil — Basicervical patterns — Reverse obliquity patterns — Displaced greater trochanteric (lateral wall fractures) — Failure to reduce the fracture before internal fixation Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA I
  27. 27. Dr. Sandeep Agrawal, .Agrasen Hospital, Gondia INDIA
  28. 28. Fvans' classification u “I t ‘I I l Unstable Unstable Unstable F. Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA
  29. 29. WHY WAS EVAN ’S CLASSIFICATION IMPORTANT? i> Because it distinguished stable from unstable fractures and helped define the characteristics of a stable reduction. - Stable fracture patterns posteromedial cortex remains intact OR has minimal communition — Unstable fracture patterns — characterised by disruption or impaction of the posteromedial corteX- can be converted into stable if medial cortical opposition is maintained. - Reverse Oblique — Inherently unstable due to the tendency for medial displacement of the femoral shaft Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA I
  30. 30. SINGH INDEX— RADIOLOGIC GRADES all normal trabecular groupa vlalbla: proximal end ol lemur completely occupied by cancellous bone principal tensile and corqpraaalve lrabeculae aceengualed; Ward mangle prominent principal tenalie trabeculae reduced in number but allll can be lracad lrom lateral cortex In femoral neck Grade 3 break In continuity oi principal ienelle Irabebulae oppoalla graaler trochanter Grade 2 only principal eornpreealve lrobeculae can be seen; all lenelle trebeculae have been resorbad Grade 1 principal eompreaelva lrabeoulae markedly reduced In number Dr. Sandeep Agraal. Agi'aseii Hospital, Gondia INDIA
  31. 31. I. People with poor bone quality --half of fractures are comminuted and unstable --excessive medialization of the shaft --subsequent loss of contact between fragment -) fixation failure 2. Even unite -- limb shortening --decreased length of the abductor lever arm 9adversely affect hip function Dr. Sandeep AgrawaI, Agrasen Hospital, Gondia IN Dl. A
  32. 32. r—~-—<: ——-~~-~. —~»-—. «—= .—, .~. —— "-‘-3.: -:r-‘-. -:. ——-. —,. -~‘ ‘e. ,, l . ‘pt, ‘ F 1:, 1 AG Classification , _.. ._-. ., an _ l . ... ... ... ... ... . _n__~ W *' ' ‘mu ' ' ‘ . ‘ l)r. bandeep Agraa| .Agrasen I*losplta| ,(; ondia INDIA 5 , ,,, ____________. __. __. .___, _.__ g . .___c __ M - . _ . _ J
  33. 33. UNUSUAL FRACTURE PATTERNS a— BASICERVICAL FRACTURES €> Located proximal to or along the intertrochanteric line. 9 Although anatomically femoral neck fractures they are usually extracgpsular and behave like intertrochanteric ractures. > At greater risk for osteonecrosis when compared to more distal intertrochanteric fractures i> Lack the cancellous interdigitation seen with fractures in the intertrochanteric region and are more likely to sustain rotation of the femoral head Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  34. 34. OTAJAO CLASSIFICATION 3|-A extraarticular fracture, trochanteric area 31-Al pertrodiantericsimple 31-/3.2 pertrochantericmultifragmentary 31-A3 intertrochanteric Di'. Saiideep Agi'aial. Agi'aseii I’IOS| )ll£tI. GOll(Il£t INDIA
  35. 35. Evans Jensen classification Type I Type II Type III Type IV Type V I“is; ‘gig; i;i; ,.“; {,: .;; ;;. ;ijilg, .;; ;.; . PIoms~pmital, iCoiidia iiviim
  36. 36. IT FRACTURE WITH LESSER TROCHANTER IN PROXIMAL F RAGMENT lrreduci ble Fracture Open Reducliioii
  37. 37. Needs Open Reduction
  38. 38. An irreducible variant of intertrochanteric fractures: a technique for open reduction G. Z.Said, O. Farouk*, H. G.Z. Said Figure 1 illustration of an irreducible variant of intertrochanteric femur Fracture. The iliopsoas remains attached to the lesser trochanter, and the Long spike on the head-neck fragment often gets caught between the Iliopsoas and the lesser trochanter. Open reduction and extraction of interposed Iliopsoas tendon is necessary to achieve a satisfactory reduction. On a standard operating table and with the patient supine. The fracture site was exposed laterally by cutting the vastus Iateralis muscle fibres arising from the trochanteric line. Firstly, full adduction and external rotation of the limb to slacken the iliopsoas tendon. Secondly, a hohmann retractor was then passed medial to the shaft, to hinge behind the fracture surface of the sunken femoral neck, Ievering it anteriorly. Lastly traction in abduction and internal rotation was done to complete the reduction. Clinically, the overriding upper shaft produces a swelling in front of the hip joint, and radiologically there is upward riding of the shaft fragment with an intact lesser trochanter.
  39. 39. OPERATIVE METHODS i> Plate Constructs i> Cephalornedullary nailing > External Fixation i> Arthroplasty Dr. Sandeep AgraWal, Agrasen Hospital, Gondia INDIA l
  40. 40. PLATE CONSTRUCTS lnipaction class ln1pact. e(l nail-type plate devices eg. Blade plate and fixed angle nail plate devices D_ynamic compression class large single slidinj; screw or nail. femoral head components with side plate attac nnents eg. Sli nig lnp screws Linear Compression class Multiple head fixation components controlling rotation and translation but allowing linear compression Gotfried PCCP and the Inl. erT/ N CHS llybrid Locking Class Multiple [ixation eoniponenls with compression initiall_v for lracliire reduction followed by locking screws which prevent l"nrt, l1er axial compression cg. Proximal Femoral Locking Plates Svvnthes, Paoli, PA and Sn1it. l1-le. pl1ew Dr. Sandeep AgraWal, Agrasen HospitaI, Gondia INDIA
  41. 41. DHS family . v‘ £. ’.'{L. '“ Q, Jo‘
  42. 42. Sl. |l)| () llll’ S(IRI*‘. 9 Gold standard for stable intertrochanteric fracture stabilization i> Good union rate. %> Low coniplication rate i> Inexpensive implant 9 Easy learning I’ Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA I
  43. 43. DHS T 9 Routine used : DHS : > But -i 9 — perform less Well in unstable fracture 9 — relative high rate of screw cutout 9 — plate pulloff 9 - long lever arm i. _._. m Dr. Sandeep Agrlawal, Agrasen Hospital, Gondia INDIA
  44. 44. a. -p. projection Sliding llip Screws 1 _v. ..i; ~u, «um ~ ' I , _ I ' . ' M4 _ cm ‘.4. _ ’ 9 I ' ‘ F —_ /3. " / 1‘ ‘ ' ’ T Iateralprojection 1: , / ‘T3C“°"‘3bl9 Supine position on lraeliire table Fl'2t(‘ltlt‘(‘ site reduction l. oiig'itndiiial traction k Etei'nal rotation Internal rotatioii ai'us angulation t l’oslei'ioi' sag Mzilrotation The lo er etren1it_ is placed neutral or sliglit eternal rotation
  45. 45. |'l'l’i l| ’.l)l l. |. l’i | l|| ’ . H'(l| ’i| ’. S 9 (lamina nail Treatment with IM device: 9 Proxiinal 1.Less invasive feiiioi'al nail 2.No better than DHS for stable fracture - Recon nail Fracture reduction (mini-open reduction) and (, t}1(, .1-5 iatrogenic fracture (re—designed Gamma IM nail) K? f? a:. ‘»’%i‘ Indication: 1. Reverse obliquity 1-if 2.Subtrochanteric extension '7” ‘l ‘ Relative contra-indication: ; I Fracture around pirifomis 3 it , _.. .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . , _ _. ___ ____ _ - _ D] Dr. Sandeep Agraal. Agraseii | *lospita| ,Gondia INDIA
  46. 46. Intramedullary nail - screw - l()ad sharind device 9 Advantages : . b . - three point fixation - shorter level arm -less tensile strain - preeutaneous insertion I311t — femoral shaft fracture 9 Mechanical 9 Biologic - distal locking screw applied K Dr. Sandeep . Agrawal, Agraseii Hospital, Gondia IN DIA
  47. 47. DHS : Bending Force is Especially Bigger Than Torsional Force Due to Longer Level Arm IM devices: snialler bending inonients than plate-screw devices
  48. 48. Loading iespniiw IC OT HR OI TO FIX TV IC tr l 9 t t Loading Terminal lnntnl Terminal response nnnce- swing fswlng Mld- - - 1 00 stance lIiv'iing 0 10 20 30 40 50 60 70 80 90100 Gait cycle ('4) Maximal ground reaction force
  49. 49. (Irueial | 'aetoi‘s alieeliiig Siirgieal ()iiteoiiies: 9 Fracture Geometry 9 Osteopenia and Bone Quality 9 Comminution 9 Surgical Techniques : Reduction Quality, Type of Implant and Implant. position 9 Delayed weight bearing 9 Implant Choice ( Fixed angle plate , TSP, Cement, others) 9 Medical Co-Morbities [7 Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  50. 50. = : Nail "; ..__': %— Lock Drive 3- ~ 1 Lock Prong t V ‘ v ‘. Helical Blade . i Locleing mecIJtmi'sm rlisengaged . "l'lllllllllll. ' locking niecbmiikm engaged
  51. 51. Reverse Oblique Fracture : > DCS 9 Blade Plate : > IM Nail / 9 Proximal Femoral LCP I 9 Resist Medial Shaft Displacement Dr. Sandeep AgravvaF, Agrasen Hospital, Gond A:
  52. 52. ANATOMY Abductors displace Greater Trochanter laterally and proximally Iliopsoas displaces Lesser l I‘ Trochanter medially and ll proximally l l Hip flexors, extensors and adductors pull ~, distal fragment 3 K proximally l[ l_)l'. Sandcep Agi'aal. Agrascn Ilospital, Gondia IR Di A
  53. 53. | (‘(| i:‘li7A£lli(’H 2H‘lI. s' . ~'| m|'l(‘IIing LOSS of medial buttress lug . '('I‘(‘ (‘III Illmllqll Adductors
  54. 54. |’| *'. lC| ’SlC ( )|3|. I(_)l Ii lmtrallse sllearing l'()r('es: L5()‘% Failu re Hillfl V| ('(lial (]iS| )]{l(‘(‘lH(‘l’1l Cxwssixe collapse on union E DI'. San(| eep Xgrzmz1|AgI'ase11 | |ospilz1|, G0mlia IND] R t . _.__ Wm, __ _. , _ z I 2 I
  55. 55. :: PFV « REDI (ITl(), ‘ 9 Closed 1“ eduction Reduction Maneuver Traction Internal Rotation i> Anatomic reduction better result > Gravity . ... ... ... ... ... ... .. Fracture fragment shaft sags posterior i> Rarely open reduction Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA l
  56. 56. REDUCTION — CLOSED REDUCTION 9 Longitudinal traction given in slightly abducted position 2> Depending on the fracture type, the amount of rotation is decided : > If proximal fragment — head and neck alone — does not have muscle attachment, remains in neutral EXCEPT in case of slightly displaced fracture Dr. Sandeep AgraWal, Agrasen Hospital, Gondia INDIA I
  57. 57. REDUCTION — CLOSED REDUCTION 5> Head and major part of GT form the proximal fragment — the external rotator muscles inserted into GT tend to rotate the proximal fragment laterally; hence we need. to reduce With distal fragment placed in some degrees of external rotation Dr. Sandeep Agravs/ al, Agrasen Hospital, Gondia INDIA I
  58. 58. REDUCTION — CLOSED REDUCTION i> In case of communited fractures, the posterior sag of the distal fragment may be corrected by lifting up with a HIP SKID under the fracture by an assistance or with the use of a crutch under the proximal thigh. 2> Post-op xrays to confirm reduction with spl. Attention paid to cortical contact medially and posteriorly Dr. Sandeep AgraWalT, Agrasen Hospital, Gondia INDIA I
  59. 59. REDUCTION — OPEN REDUCTION : > Failed closed reduction 2> Large spike on proximal fragment with lesser trochanter intact i> Reverse oblique fracture i> If a gap exists medially or posteriorly Dr. Sandeep AgraWal, Agrasen Hospital, Gondia INDIA I
  60. 60. OPEN REDUCTION TECHNIQUES i>Anatomica| Stable Reduction applying a bone holding forceps across the fracture in an anteroposterior plane while adjusting the traction. and rotation if the fracture is not severely comminuted. é> Once achieved — compression hip screw or other device can be used to secure the reduction Dr. Sandeep . AgrawaP, AgraseI1 Hospital, Gondia INDIA -_I
  61. 61. OPEN REDUCTION TECHNIQUES 2> Non-anatomical stable reduction — in case of severely comminuted fracture where anatomical reduction is difficult or impossible. Done to convert it into stable fracture Dr. Sandeep . AgrawaP, AgraseI1 Hospital, Gondia INDIA -_I
  62. 62. NON-ANATOMICAL STABLE REDUCTION TECHNIQUES 9 Medial displacement osteotomy a. k.a Dimon — Hughston osteotomy a. Transverse osteotomy of the proximal femoral shaft at the level of LT b. Osteotomy, if necessary, and proximal displacement of the greater trochanter and attached abductors c. Medial Displacement, of the femoral shaft d. Impaction of the proximal fragment into the medullary canal of the femoral shaft Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA I
  63. 63. NON ANATOMICAL STABLE REDUCTION TECHNIQUES é> Disadvantages of the technique include — limb shortening, level of function and proximal migration of the GT significantly comprises abductor function increasing the stress on the implant and impairing patient’s ability to walk. Dr. Sandeep Agravval, Agrasen Hospital, Gondia INDIA I
  64. 64. NON ANATOMICAL STABLE REDUCTION TECHNIQUES 2> Valgus Osteotomy (Sarmiento Osteotomy) which involves a. An oblique osteotomy of the proximal femoral shaft extending from the base of GT to medial position lcm distal to the apex of the fractures b. Implant placement into the proximal fragment 90 deg to the fracture surface c. Reduction and impaction of the osteotomy surface Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  65. 65. NON ANATOMICAL STABLE REDUCTION TECHNIQUES i> Pitfalls associated with this technique : a. Excessive Valgus osteotomy which increase the force required by abductors to stabilize pelvis increased joint reaction forces b. Excessive limb shortening c. External rotation deformity Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  66. 66. NON ANATOMICAL STABLE REDUCTION TECHNIQUES : > Lateral displacement a. k.a Wayne County Osteotomy which involves lateral displacement of the femoral shaft to create a medial cortical overlap. fi> Applied to those relatively unstable fractures with a posteromedial fragment Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  67. 67. ASSES. lEV'| ‘ OI? |{l*Il)ll(‘. 'l‘l()N 9 1. Displacement 9 2. Neck-shaft angle 9 3. Anteversion 9 4. Shaft sag 9 5.Translational Displacement Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  68. 68. PROXIMAL EEMORAL NAIL 9 The PFN nail has been shown to prevent the fractures of the femoral shaft by having a smaller distal shaft diameter which reduces stress concentration at the tip. 9 Due to its position close to the Weight-bearing axis the stress generated on the intramedullary implants is negligible. Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  69. 69. PROXIMAL EEMORAL NAIL 9 PFN implant also acts as a buttress in preventing the medialisation of the shaft. The entry portal of the PFN through the trochanter limits the surgical insult to the tendinous hip abductor musculature only , unlike those nails which require entry through the piriformis fossa. Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  70. 70. « D . ’l‘»( ; E < )1: PI‘ l 9 Efficient load transfer 9 Shorter lever arm decreases 9 tensile strain on implant 9 Controlled fracture impaction 9 Less screw sliding Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  71. 71. ~l) "l7(lE ( )l*‘ l’| W 9 Less limb shortening than sliding hip screw 9 Shorter operative time 9 Less soft tissue dissection 9 Decreased blood loss 9 Biological fixation Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  72. 72. DIs. D *'| ‘i(; l+1()I<‘ PFV 9 Can not used in small femur 9 Cannot use in deformed femur 9 Less impaction 9 Smaller diameter of bolts Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  73. 73. PR()(Il*]Dl RE FOR l’l<‘ 9 Position supine on fracture table 9 K-Wire Fixation after reduction 9 Entry point at greater trochanter 9 Entry point to be reamed 9 Nail not to be hammered 9 Static distal locking Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  74. 74. II. ‘sm: ( gnizlo :1 '. 'I'¢' (. 'm: ,"irm rude uwrp! acwrIc'r1!—. ~1l’
  75. 75. '| ‘iI+‘. (1|"l7[(‘. I| . TIPS 9 Assess pre-op. neck shaft angle 9 See for Excessive anterior bowing of femur 9 Assess medullary Canal diameter 9 Assess reduction of fracture 9 K-wire fixed in both AP/ LAT sup Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  76. 76. 9 Patient position- 9 on fracture table : > Adducted shaft- 9 Avoid fixing in the varus 9 Solutions 9 Maintain ankle dorsiflexion-for good traction & rotational control : > In obese & unstable — scissors position 9 Both feet traction- fractured leg adducted & slightly flexed. Well leg abducted & extended. Confirm clear Ap & Lat View in II Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  77. 77. '| ‘iI£(1|”l? "[(1/| . TIPS 9 Closed reduction 9 Define major fragment translation & angulation 9 Appreciate proximal fragment rotation along neck axis 9 Consider hip flexion— raise thigh support. Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  78. 78. '| ‘|C( II I V | ( I I| .'| ‘| PS courtesy : Dr. Prasoon Anand Ta I :1 I 111921 r 9 Use K wire after the reduction it maintains the reduction. 9 AP - superior 9 LAT- Inferior I’ Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  79. 79. '| ‘iI+‘. (1|”l"l(‘. /| . TIPS 9 Mild varus due to extremity adduction for nail insertion is temporarily accepted. Abduct the extremity & add traction after nail insertion to get Valgus reduction 9 Percutaneus- K-wire 9 Ball spike pusher 9 Ball tipped acetabulum reduction forcep Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  80. 80. :> IDENTlFIl_I G 61 CREATIN G ENTRY 9 _'Iark shaft axis 011 thigh to reduce radiation 9 Percutaneus insert guide pin 9 Enter at tip or slightly mcdially. ... lateral entrance varus 9 Advance the piI1 until it deflects off the medial cndostcal s1Il)trocl1anteric cortex Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  81. 81. '| ‘iI<‘. (1|”t*t(‘. /| . TIPS 9 Always do one step reaming of proximal femur 9 Do not displace the fragments 9 Medial directed pressure While reaming 9 Typically- reaming NOT necessary Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  82. 82. '| ‘iI+‘. (1|"t’ I(‘. i| , TIPS : > IMPLANT ASSEMBLY & INSEBTION: 9 135 or 130 degree 9 With out hammer- 9 If resistance- soft tissue 9 Anterior cortex impingement-bow 9 Narrow isthmus. Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  83. 83. 9 Placement of Femur neck screw and Hip screw 9 Guide pin parallel to neck 9 Correction AP plane- Traction/ abduct 9 Correction Lat Plane- rotate/ lift jig 9 Hip screw. ..15-20 mm less than Femoral Neck Screw—derotation 9 Femoral Neck Screw. . . ..near neck distal cortex. . . .CALCAR Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  84. 84. '| ‘iI+‘. (1|”t't(1i| .TIPS 9 Need of distal locking? 9 Release all traction determine Fracture stability 9 Two screws for gross length instability 9 One for rotational stability 9 Locking not necessary for stable fractures Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  85. 85. '| ‘iI+‘. (1|"t7t(‘. I| . TIPS 9 Post operative care 9 Allowed wt. bearing in stably fixed fractures. 9 With normal bone architexture. .. - full weight bearing 9 Abduction exercises immediate 9 Encourage full wt. bearing as pain. Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  86. 86. '| ‘iI+‘. (1|"t7t(‘. I| . TIPS 9 Key Decision point- 9 Acceptable —biplanar reduction is achieved ? If NOT 9 Proceed with limited open reduction : > DO NOT NAIL MALREDUCED FRACTURE Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  87. 87. 1 I li)r. San(lcep g’t‘zIItli: A;t'ttiSI; IlII Iospital. (}on(Iia lI)l
  88. 88. CASE 2 Fracture Lateral l)r. San<lccp graaI. -grusen IIospital. (lontlia ll)l
  89. 89. How to improve out come. I . ln1pIant positioning 2.T~D. ... ..v-525 ">. l.ateral wall reconIstruction 4.Augmentation
  90. 90. l. lnIplanl positioning | .>w(Im_li”” (. entcrc<l In II| (‘ I‘('lll()l‘: lI llcml l’ it* t' l. at Ie ot (lenter in the (‘(‘I lligll ngIelInpIz1nt linnv In Rune <-Onl: It't I1lll'(‘(lll(‘lIt)ll loss (bl. sta| »ilit_ l. 'Il'; u-lion 2'()p| :‘ (i(‘IlI(‘I'(i('lll(‘l'-II(‘2I(I , _ , _' ) __ -; .5”g. :H, .l"g. lnipoIt.1nt . nIal>l( Ill I)()tl( Implant (i()II. ~'. lt‘lI('l I)r. San(lccp graaI. *grasen IIospital. (}on(Iia II)l
  91. 91. e Proximal femur. Cadave} specimen. a. 70-year-old man: the cancellous bone 05 the femoral head is still dense. Adam's arch thick, but the cancellous bone ofthe neck is poratic: b. 91-year-old woman: cancellous bone of the head is preserved but porotic; great pans of the neck [Ward's triangle] and the trochanteric area are already hollow, the lateral cortex and Adam‘; arch are srnaler With advancing age Ward’: triangle between HIE two bundles of traheullae in the middle d the fernoralneelrbeearneav le. AIaeaeeompaniediy The~‘°'eweaIways°an°°uM°na9°°d increasing osteoporvaia the number at trabeclllae Punfluse uceseuen and finally they Iiaappear being replaced 07 screw! in the Matt Depending on the degree by tat. it follows that the cranial implant is not supported at nsteoporosis the slab" ity can be increased by inlide ‘M ne¢| I- choosing screws of a larger diameter or by the To the eomrary. in the head no cavitiu Ionn similar “union la Ward‘: mangle. Even In older peraona the M 56”“; on me "be, hand. one should always aubehondral bone mass atthe weight bearing amlaee in ‘Hum obtain a good subchomiral fixation
  92. 92. Irnplant positionillg Accuracy and Precision Not ac Accurate and —§ , . , no (curate not precise ' precise l)i'. Saii(| (>cp —gi'zi2i| . f_>; i'z1s. (*ii Ilospilz1|. (}(_m(| izi | l)| 'c_. .__, ... .__J
  93. 93. 2.TAD 2> T. /. D. <: 25 mm 3> / ilchin one Cm 0I"s1ii)(: l1<)i1(| i'a| hoirc 2> V(rJl rc(l11(: ti0r1 and (: ()111p1'cssi()11 9 Length of Lag screw Dr. Sandeep AgrzrwalAgrasen Hospital, Gondia | i DIA I
  94. 94. 'I‘i| )- p(» DlS| £ll](‘(‘ 'I‘I)~ '| ‘I_) Sliwtig l’i'm| i('loi' <>l'(Iul ()nl '| ‘i”) ‘_3inni | “£llllll‘(‘ | )|>m:1<'| i(‘s 7mi'<> '| '| ) '_3Inin (llizmr-v oi’ l'zrilur'<' ll](‘l‘(‘ilS(‘. ~'. l‘1i[)l(”_
  95. 95. .. ... .. ... ... _ u. H. .. nil. -r| |—A ula SUPERIOR $0-fllll-IUJOU Baumgaertner et al. JBJS (A) 1995 Proaabmrv °*°. 01 V Cutout 0.4 ; Dr. Sandeep Agrawal, Agrasen Hospil IncveesInsTAD ———- wm 4
  96. 96. 3.Rec01rstruct Q1" Retain Lateral W_'ail . _J‘ viUi-«H1-or’ 4- ri—Io£>r7« Di'. San(leep AgitrxrzrlAgrasen Hospital, Gondia IN D} A a
  97. 97. :> Important cause of instability $> Buttressing effect prevents collapse > As important as post. Med. fragment instability i> Due attention not paid Gotfried Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  98. 98. THE LATERAL WALL i> lat1‘og(>11i(‘ C0n1n1i11nti011- lmpropci‘ ont1‘y for l)a1‘rcl ic'a: Ln, ,s'Ha ssims 9 Place angle gniclc fi1‘n1l_AV [— Dr. Sandeep . rigrawal, Agrasen H ospital, Gondia INDIA
  99. 99. 31%. - 'A2 Type Fractures ¢’ 31. A3. 3 Integrity ofthe l. ;1tcr;1l l-‘cmoral W211] in lntcrtrochantcric Hip l-‘racturcs: An Important l’1'cLlictor' ofa Rcopcration In It. -u; .L Lulu. ! :- i. er. i. l. ... t.. ..i v.1-~~ai_. <_-—. ..r. Ir. .: I. ‘cut | v'. . . ..-. 5'. r.. '. rl-will u~ <'I4 I-l Arm nu. It. ,- | ... r.. .. ~v. ..h «. ... ., - . v.r' ~u, 1.. rr. t.. .. l- ’c__. ._. _ l_)i'. San(lcep gi'aa| , ~gi'asci1 l | ospila| ,Goi1(lia IA DI A
  100. 100. Retaining Wall Iil '| "|‘| ’ICS. ' IC | <‘| “ | ’.( TI‘
  101. 101. IF LAT WALL COMMINUTION RECONSTRLCT : i> l. Trochanteric T SP Plate {7<"I / .2 Xi“ / i> 2. Derotation Screw 2> 3.Tension band wire 2> 4. Double barrel I’ Dr. Sandeep Agrawal, Agrasen Ho~spital, Gon(lia INDIA
  102. 102. Tiochanteric Stabilizing Platé (TSP) (Madsen JE, 1998; Babst R, 1998)
  103. 103. DI'. San(| eep gi'2121|Agrasei1 | i|ospilz1|, (jondia | iDl ~ . 1 » 1 ‘, 0 ' ‘ “ 1 ' - 4 ‘i q ‘ ‘ 47 u 3 i ‘ ‘-5 ‘ . . -‘ , § ’ 3 '1 ___, .N. :4
  104. 104. PLATE CONSTRUCTS — TRO CHAN TERIC STABILIZIN G PLATE > The trochanteric stabilizing plate and the lateral buttress plate are modular component. s that buttress the greater trochanter. i> These plates are placed over a four-hole sideplate and are used to prevent excessive slide (and resulting deformity) in unstable fracture patterns. i> These devices prevent telescoping of the lag screw Within the plate barrel when the proximal head and neck fragment abuts the lateral buttress plate. Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA l
  105. 105. PLATE CON STRU CTS — LINEAR COMPRESSION CLASS i> A. K.A Rotationally Stable Plating — adds enhanced rotational stability with multiple screw fixation in the femoral head i> Examples — Gotfried PCCP and InterTA. N CHS Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA l
  106. 106. 4.Augmentation 5> Cement Severe Osteopenia Augmentation Po; ymet, h_yl l*Iethacr‘vlat, e (PMMA) Improves Screw Purchase ' / ugment Deficient Medial i> Bone Graft i> Bone Substitutes C (jorlex V C Prevent Screw Cut Out 3> Ca-P Cement Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  107. 107. I Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA i: _._
  108. 108. (I| Cl| {'| ‘ l (}lli'| ‘'| ‘|() I Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA 1
  109. 109. ° The stability of an intertrochanteric fracture depends on —-the degree of Comminution ——osteoporosis --fracture configuration - Malreduction 9Reduced bone-to-bone contact 9 loss of stability - Eccentric placement of an implant -)increases the risk of cutting out -9 add to the probability of fixation loss iatrogenic comminution of the lateral cortex during the operation. --loss of the buttressing action of the distal fragment --leading to medial displacement of the distal femoral shaft One technical problem(1ateral fragmentation) --creation of an improper entry angle hole with regard to the plate angle élevering on the lateral cortex. (fails to firmly position the angle guide on the lateral femoral cortex) Dr. Sandeep Agrawal, Agrasen Hospital, Gondia llDl. A
  110. 110. |)| |S S(I| ’| ’. | i) | )li| ’t()T'| ‘|() S(I| ’| *I | ’l’t | i|. |C| . Screw thread touching barrel Converts into rigid device 4''; 3 — Cutout ii‘- * — Penetration — Stops further collapse — Nonunion l Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA tjj
  111. 111. Sim et al. J Trauma 2000 femoral head . ‘ timers! nezg, A '38 SCI: barrel '3" 4;, “ I I frncmigpr , V’ . E Ix/ y_, lF0’/ "m/ kg awwmmrzaa 9 is , _-_ . ... ... ... ... ... .. I ___________________________________________________________________________________________ IIIIII . ... . g ______ s- _ 7 I‘. all( 66‘ ) "l'2l 21 . ' "'I'dS€ll ' OS )I ll , OIl(, lit ‘ us I lab Mg II | tl(J I IMJM I ____ . _"______. __i_______. __. ._____. _,. a_ V~<d _ . . . s_. _ r1 . . _ I--. _ . l
  112. 112. Cut—out Due to Lag Screw Jam It l_)i'. San(lecp Agraual. Agrasen I Iospital, (}ondia lb DI A
  113. 113. Plate Failure Due to Lag Screw Jam , .__ . ... ... ... ... ... ... _. V . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. _ s_, I Dr. Sandeep Agi'aal, Agi'asen IIospital, (;ondia llDl A . ... .. _L_____L___a___-_____. ._. .__. __. _,. a_ V~<d . . H . . __ s___. _ . _ I
  114. 114. Galanakis et al. Clin Orthop 1995 Using Doppelt Method TABLE 3. Mean Value: of the Sliding Screw Migration for the Vaflous Areas of the Femoral Head Antaropostarior | "“"" n‘d'°9"‘ph Radiograpti Anterior Middle Posterior n = D n z 6 vi = 1 Superior Migration Migration = O 7 cm Migration = 1 cm 9 < OIXXD5 n = 2 n = 16 n = 5 Middle Migration = 0.7 cm Migration = 0.17 cm Mig'al| on = 0.8 on p < ODO5 p < 0.1135 n = 2 n = 3 n - 2 Interior Migration = 0.5 cm Migration : 0.6 cm Migration —— 1,9 cm [.1 < 0.05 p «z: 0.01 p < 0.5300005 TABLE 4. Mean Values ot the Bousquet Nail Migration tor the Various Areas of the Femoral Head AP [aural Radlograph Radiograph Anterior Middle Postenbr n 0 n = 5 r = 0 Superior Migmticn Migration = -3.7 Cm Migration p .3 0.05 n = 0 n = 17 l‘ = 5 Middle Migration Mgrat-on = 0.5 cm Migramii [1 7 em [1 : - 0.05 n = O n = 3 ii - 2 Interior Migration Migration = 0.5 cm Migration r 1.2 cm 0 : - i’J. !JEi p > 0.35 Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  115. 115. Potentially Unstable lntertrochanteric Fractures ---J Orthop Trauma 2005 - The use of a long barrel: - there is a higher risk of iatrogenic comminution “ Pmemial for Causing C0mmiflUfi0n Of the in low intertrochanteric fractures with the lateral “max proximal end of fracture exiting near the the lag - if the long barrel goes proximally to the fracture site and the proximal fragment has to slide over the barrel 9--resulting in protrusion of the sliding screw --induce or start further comminution of the greater trochanteric piece screw hole éiatrogenic comminution of lateral cortex was the most significant risk factor for loss of initial reduction. t___, .N. :4 Dr. Sandeep gi'2ia| AgI'asei1 | lospil21|, Gon<_lia | lDl ~
  116. 116. 71 i l X ‘%"#7fv"?7fi—' 7 A ””: ‘—~4‘“ WWW My-Tm” mi‘ Malreduction Shortening COMPLICATIONS: F '2, - Loss of Fixation E - ‘ Nonunion ' r’ Malrotation deformity I‘ Penetration :1 '} shortening in . ; z i Guide Wire Penetration Mechanical Failure Cut out . _.. _.. __. _.. ‘____. _ . ... ... ... ... ... ... .-_ . ... ... ... ... ... ... . . ... .. . -V . ... . . ._ '. ... ..A. .. ... ..~. ... - e .1 i[ Dizbantleep Xgrzma| AgI'asei1 I | ospilz1l, (;oml1a IN Di R
  117. 117. Screw Dissociation , . , . " li<il| i'l<‘: ~;‘ i)l‘. il)<*. 'tl i)lz: :; i| if en VH(, 7’
  118. 118. |‘I(I| CSS| ' I’. (I( )l, |. | ’S| *‘. 9 Shortening LLD i> Abd. Weakness i> Troch. impingement : > Thigh Pain 2> Screw threads impact on barrel E Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  119. 119. Management Acceptance of the deformity Revision ORIF, may required bone cement Conversion to prosthetic replacement
  120. 120. lntertrochanteric Nonunion SJ Treated with Subtrochanteric l_)i'. Samleep gi'aa| . —gi'asen I | ospil2tl, (;()mlia lh Di A _ t. .i. --__, _._i. __~_-. __. .._t ____. __m __. .W, _._i. ._n_ _______i__i___, _,
  121. 121. COMPLICATIONS i> Loosening -‘ ,4 .3 ~, ,_s, i 2> Delayed union I V :1 i> Non union , i> Knife effect-cut ~'V Ian Z . out ‘ I I Ei‘i‘mi ii It Dr. Sar1deep Agrawal, Agrasen Hospital, Gondia INDIA I
  122. 122. . . » _ . . . _ . . . M _ a. r;. _.. ,.. . __4.. ._. .._. ... __. ..4.. . . ... ,.. _,. , . .._. .,. ..~__. ... ... .,_, .4,. . . ,__. .4.. .. . ,A. . ... ... _.. ... . . ... _ . .., V _. ._. ... n. . :.. .}. ... _ . ... n__ . _ . _ I , ..i I Dr. Sandeep “£c{l‘2l2lI. rgl'aS€l] | *Iospita| ,(; ondia INDIA , ,,, ._, ______. _____~_____. _.. .__. ,_. __ L4<‘ ~< ~dhd . . '~< r1 . _ , __ _ . _ I
  123. 123. Prosthetic Replacement i> limited used in interoehanteric fracture 9 Loss of femoral neck and calcar support > Loss of great trochanter-abductor mechanism i> Extensive operative time, blood loss i> Increase morbidity and complication D But easier and faster rehabilitation, lower incidence of pressure sore, pulmonary disease, early full weight bearing Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  124. 124. l’rosthesis (Ia| (':1r ’(*pIa(‘iiig I’rostIiesis IIl(II('2llI()| l.s' ’; tlI1<>Iogi(' l“l'il(‘Il| I'(‘ S<‘<~r(‘ (). s'l(‘()I)(‘lll2t S(‘(‘i‘v (i()ll]lllllllllII()ll Rlieumaloirl rlIirilis |3(*n(*Ii| s ICar| _ <‘ighl I3(*21rii1g I')l, '()l)I(‘lllS (il‘(‘: ll(‘| ‘rIIl‘()('Il{llll(‘l‘ I I Dr. Sa—r-ideep Agrawal, Agrasen Hospital, Gondia INDIA
  125. 125. I Treatment with hip prosthesis Remained controversial Calcar replacing Long—st. em cemented implants Plus Internal fixation INDICATIONS : l. Failed internal Iixation 2. Pathologic fracture 3.Neglect. ed fracture with deformity 61 poor bone stock Relative indication: A. Ad_juvant symptomatic OA hip B. Unfavoral)| e fracture patterns with poor bone stock Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA
  126. 126. :> J Bone Joint Snrg‘ nI. I985) Sep:7lX21211-23.lelated I ' €> Treatnienl ofunstalile intertroelianterie and StlI)lt't)(‘lIfllllt‘l‘l(’ l'raetuI'es in elderly patients. l’riuiar_ bipolar arthroplast_ eonipnred uith internal liation. llaentjeus l’. (lastclt-_n l’l’. l)e Bot-elt ll. llandellierg | *'. ()pt| r-rain I’. Department oftirtliopaerlirs and 'l'i*:1tt| ||at<nlog_. rije I niersiteil lirussel. lit-lgitun. 'l'l1irt‘ -5l'(‘tl t‘(llISt't'tllI(' patients lio uere more than St'(‘lll‘-Il("('1tl‘S old and had an llllSlZllJlL‘ iiitertroeluuiterie or 5tll)lt'()t'llitIlI_L‘l’Il' fracture ('l‘t' treated In} pri| nar_ liipolar artliroplast_ from 1983 through l‘J8(i. 'l‘lie l'unt-tional results. aet'or(ling lo the rating seale of , Il: I‘l(' d' uliig'Iie. ('l'(' rated as good or eeellent in 73 per rent of the patients and remained almost unelian; .{etl itli time. Roe: itgenograpltie follon-up slirmerl eat'l_ hone forination zu'nun<l tlie e| ra| nt-dullaI'_ part ofthe Ii-inoi'2tl eoniponenl. The results in this prospeetiw group ufpatients were eoinpared llll those in a siniilar I)tIl rell ispectiw eontrol group ol'lin't_~to patients lio uere treated l>_ internal liation from 1979 Ilirougli I982 and in wholn ea 'l full weiglIt-hearing was not possible. In the liipolar artliroplast group. relialiililztlion was easier and faster. and the ineidenees of pressure sores. ]! lIllltUllZll‘_ infeetion. and ateleelasis “ere siguiiicautly loner ll» less than (i. (). 'ri. 'l'lie earl) ualltiug illi full eiglIt-hearing that the liipolararlhroplasl) made possible is eonsirlererl to he a major contributing l'a<‘tor to these results. Dr. Sar1deep Agrawal Agrasen Hospital, Gondia INDIA
  127. 127. i> 100: > 75 unstable intertroch Bipolar in 91 and thr in 9ric or. The functional results according to the Merle d'Aubigne hip rating scale were excellent. very good or good in 78% of t. he hips. The dislocation rate of 44.5% ir1 the patient group who underwent total hip arthroplasty was significantly higher than the . '%. .“i"o in those who had bipolar arthroplasty. Associated with the dislocations was a Inuch higher incidence of pressure sores and pulmonary complications. Adverse effects on the femoral side included 4 cases with progressive loosening of the screws used to fix the greater trochanter to the femoral component, I fracture of the distal femur and I pseudarthrosis of the bone envelope surrounding the femoral component. Acta Orthop Belg. l994;60 Suppl l: l24—8. haentjens et al Dr. Sandeep Agrawal, Agrasen Hospital, Gondia INDIA I
  128. 128. Disclaimer This presentation is prepared for doctors in general. . Some graphics and jpeg files are taken from Google Image to heighten the specific points in this presentation. - If there is any objection/ or copyright violation. please inform drsandeep123@gmail. com for prompt deletion. - It is intended for use only by the doctors of orthopaedic surgery. . Views expressed in this presentation are personal. - . For any ' "anal-Nu | °'fl| -*0:': °'Q'|1 ’ confusion please Contact the sole author for clarification. - _ . I, ' - Every body is allowed to copy or download and use the material best own In a poamvn my-«Inna i iumukomvvnbuohorbomovbolii II 0060' suited to him. There is no financial involvement. - For any correction or suggestion please contact drsandeep128@gmai| .com. DI'. San(leep AgrzmialAgrasen Hospital, Gondia IN DIA

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