of the femoral neck and intertrochanteric fracturs股骨颈骨折和股骨粗隆间骨折课件

Fractures of the Femoral Neck and Intertrochanteric Fractures Knut Strmse, MD PhD, Orthopaedic Department, Aker University Hospital, Oslo, Norway Classification of fractures in the proximal femur The Comprehensive AO/ASIF Classification (Mller et al. 1990) of fractures in the proximal femur The comprehensive classification of neck fractures of the proximal femur Pauwels classification of neck fractures (1965) (based on the angle the fracture line with the resultant of forces (R) Gardens classification (based on the relationship of the medial trabeculae in the head and pelvis) Reported annual incidence of hip fractures per 100 000 of population (Parker and Pryor 1993) Sweden165 Canada103 Finland91 UK86 USA80 Malayasia70 Israel 59 Korea34 population 4 000 000 1979: 6 800 1989: 9 900 1999: 11800 (290 per 100 000) Number of hip fractures in Norway 1979-1999: We have to define our problem A g i n g 2 1900 1930 1960 1990 1997 2000 2020 2050 Cooper C, Campion G, Melton LJ (1992) Osteoporosis Int;2:285 -289 6.25 million is an estimated number of hip fractures world wide by 2050 Increasing world population and increasing life expectancy seems to be the most important reason for this increase Why do we experience an increase the number of fractures? Falling frequency increases with age Porosity of bone increases with age Cooper C, Campion G, Melton LJ (1992) Osteoporosis Int;2:285-289 Determinants of fracture risk -Neuromuscular function -Environmental hazards -Time spent at risk Type of fall Protective responses Energy absorption Geometry of bone Bone mineral mass Quality of bone Risk of fall Force of impact Strength of bone Risk of fracture Choice of Treatment policy Grade of dislocation (Garden 1972, Thorngren 1991) Size of head fragment (Benterud et al. Acta Orth Scand 1994) Posterior comminution (Benterud et al.1997) Osteoporosis (Bentley 1972, Riska 1969, Anderson 1969, Thorngren 1995) Fracture related pattern of femoral neck fractures representing risk for osteofixation failure, non-union and avascular necrosis Impacted fractures are reported to have less incidence of non-unions (Bentley G, JBJS;50 B:551,1968, Raymakers, 1993) Impacted fractures develop less segmental collapse in avascular necrosis of the head ? Fracture related pattern of femoral neck fractures leading to a “treatment policy” Crawford reported 12 % of avascular necrosis in 50 impacted fractures out of 339 femoral neck fractures with an overall incidence of avascular necrosis in 37% (Crawford H, JBJS; 47 A:830,1965) Preservation of the femoral head or hemi (total) arthroplasty? Julius Nicolaysen (1831- 1909), from Bergen, worked as a Professor in Oslo. He nailed a medial femoral neck fracture in 1893, 2 years before Wilhelm Konrad Rntgen discovered the X- ray Osteoporosis is frequent not the main problem Fracture pattern is often different as to the older patient Prosthetic replacement as a primary treatment alternative has to be chosen with greater care than in the older patient Femoral neck fractures in the young or “young geriatric” patient have different aspects as to the older patient Transcervical and subcapital femoral neck fracture (31 B and 31-C3) in the “young geriatric” patient Hip replacement (hemi or total arthroplasty) represents an internal amputation with all its implications Preservation of the joint (as in all joint fractures) should be what we aim at in the treatment Secondary failures like secondary osteofixation failure as well as segmental collapse may be handled by secondary arthroplasty “Primary and secondary Charmley-Hastings hemiarthroplasty in displaced femoral neck fractures and their sequelae” Benterud JG, Kok WL, Alho A. In: Ann Chir Gynaecol 1996; 85(1):72-6 What do we do with the impacted femoral neck fracture (31-B2) ? Functionally treated: No.of PatientsAgeInstable 59 15-69 2 = 3% 73 70-94 16 = 22 % Raaymakers 1993 What do we do with the impacted femoral neck fracture (31-B2) ? In the literature we find: Instability: After early mobilisation without weightbearing: 8-19% After immediate full weight bearing: 32-65 % What do we do with the impacted femoral neck fracture (31-B2) ? Mortality in impacted femoral neck fractures: Operative treatment 10 % Conservative treatment 1.8 - 3.3.% (Raaymakers 1993) What do we do with the impacted femoral neck fracture (31-B2) ? Retroversion is not an important reason for higher instability (Raaymakers 1993) “It is impossible at the time the patient presents himself to predict which fractures will undergo desimpaction” (Bentley,Crawford, Judet, Asser, Hansen, Famos,Jeannaret) What do we do with the impacted femoral neck fracture (31-B2) ? Conclusion may be as follows: Age less than 70: Internal fixation in situ Age more than 70: Conservative treatment. If secondary dislocation or AVN: Arhroplasty Timing of Surgery In dislocated femoral neck fractures As preservation of the femoral head is the main goal of our treatment surgery should be performed as soon as possible and latest within 6 hours The value of decompression of the intracapsular haematoma still is unknown Timing of Surgery. If not immediate ? In dislocated femoral neck fractures The value of immobilisation in traction is questionable in concern of development of avascular head necrosis Positioning of the hip in the most comfortable position to the patient probably also is the position where the intracapsular pressure is at lowest Is the viability of the femoral head predictable? By fracture classification? By scintigraphy? MRI Intraoperative by bleeding? Intraoperative by measuring of electric potential with temporary implanted platine electrodes and gas insuflation (H2O2)? Preoperative Intraoperative In femoral neck fractures Is the viability of the femoral head predictable? MRI Reduction technique in intracapsular fractures of the femoral neck Loosen the fracture by “unpack” it After having obtained the reduction “pack the fracture” and then fix it Mark Flynn injury 1973 Impacted fracture Non displaced fracture Displaced fractureReduction manoeuvre (Leadbetter) Impacted fracture Intracapsular fractures of the femoral neck Internal rotation of the foot should result in the femoral head, neck and shaft all appearing in a straight line with no residual anglulation at the fracture site dorsal ventral Choice of Implant Choice of Implant Cannulated bone screws Non cannulated bone screws Nails with hooks (Hansen nails) 130 0 Angle blade plate Sliding Screw Plate Systems (DHS, HCS) Implant demands The implant shall provide stability - prevent dislocation in varus - prevent dislocation in retroversion - prevent rotational micromovements Allow axial sintering along the implant without penetrating into the joint In case of delayed union and non union migration into the joint/pelvis should not be possible Choice of Implant: Sliding Screw Plate System Choice of Implant Benterud JG, Husby T, Nordsletten L, Alho A: “Fixation of displaced femoral neck fractures with a sliding screw plate and a cancellous screw or two Olmed screws. A prospective study of 225 elderly patients with a 3-year follow up”. Ann Chir Gynaecol 1997; 86 (4) 338-42 Choice of Implant Ann Chir Gynaecol 1997; 86 (4) 338-42 Conclusions. Both treatment methods resulted in high rate of osteofixation failures (18.5 % in the SSP group and 19.5 % in the Olmed group) and non-unions (6.2 % and 8.5% respectively) Choice of Implant In 31- B2 fractures of the “young geriatric” patient a 4 hole DHS with an antirotational screw, however, is the implant of choice. The fixation on the tensile side of the femur and gliding cylinder for the screw provides stability over time Choice of Implant Angle blade plate and cancellous screw Femoral neck fractures: If screws: Two or three screws? Position of the screws? Dimensions of the screws? Three screw fixation technique in fixation of cervical fractures of the proximal femur Choice of Implant Screws with head and washer preventing axial migration in instability Screws without head and equal diameter of thread and shank Fate of the medial neck fracture after ORIF Early osteofixation failure in 8-16 % Non-union in 8 -10% AVN in 6-10 % This makes an overall failure rate of 20- 30% but- in the first year after a medial neck fracture 25 % of the patient are dead to unrelated fracture desease Classification of trochanteric fractures (31-A 1-3) Bone mass related to age in cancellous bone and cortical bone 100 years 50 years Bone mass Trochcanteric area Neck of the femur Age Fractures in the proximal Femur at Aker Hospital, Oslo,Norway1999 DiagnoseNoMedian age male female Cervical Frx 282 84 (29-104) 53 229 Pertrochanteric Frx 186 88 (54-102) 75 111 Subtrochanteric Frx 37 86 ( 39-95) 20 17 505 148 357 Biomechanichs of the proximal femur Biomechanichs of the proximal femur Biomechanichs of the proximal femur Fracture pattern reflects biomechanichs of the proximal femur in different stages by falling Falling activates tensile forces of the muscles Falling induces rotation of the femur on the fixed leg Forces act on the trochanter by direct contact at the end of the fall In unstable trochanteric fractures in the elderly the implant chosen have to: respect the instability of the fracture allow fracture impaction during motion without fixation failure secure retention of the fracture in acceptable position during healing build a biomechanical construct with the bone allowing early weight bearing 31-A3.3 Fracture. DHS and TSP Week 8 Week 0 sliding screw -plate system allowing the fracture sintering plate on the tensile site neutralising tension forces Trochanteric Supporting Plate preventing femoral shaft medialisation Additional antirotational screw 31-A3.3 Fracture., The -nail sliding screw-nail nail in the centre of the femoral axis reduction of the lever arm no neutralisation on the tensile side sintering in varus with “cutting through” 31-A3.3 Fracture. The -nail Day 1 Day 126 Day 160 In unstable trochanteric fractures in the elderly the implant chosen have to: respect the instability of the fracture allow fracture impaction during motion without fixation failure secure retention of the fracture in acceptable position during healing build a biomechanical construct with the bone allowing early weight b