4/14/2012

What is the Contemporary Solution to majority of Hip Fractures ?

Anatomic Reduction of Hip Pathology

E. Egan Johnson, MD University of California-Los Angeles Jeffrey Mast, MD University of California-Los Angeles

IM Hip Screw Short Proximal Femoral Nail DHS - Dynamic Hip Screw Proximal Femur Locking Plates

Blade Plate

Intra-medullary Devices Proximal Femur

Popular - WHY ? Advertised Simple Technique Minimal blood loss Can manage all kinds of fractures Weight Bearing devices ? Impression of less skill required to insert Anyone can do it ..

Intra-medullary Devices Proximal Femur

Problems Varus collapse Shortening External Rotation Excessive Bone Removal Prominent Implants Nonunion Implant failure Removal Large Amount of Bone

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Cavitary Lesions IMHS Implants

17 MM reamer for proximal femur Lateral Nails ream Medius Insertion Second ream into femoral head Removes tension and compression trabeculae femoral head and neck

Total cancellous bone loss ??? cc3

Bone Volume Removed

IMHS Hip Screw
180 160 140 120 Volume in cc 100 80 60 40 20 0 IMHS IMHS Hip Nail Lag Screw IMHS Sleeve Nail Vol Vol Measured Vol Calculated

IMHS Implants Popularity

Popular in residency programs / community Younger surgeons tend to like implant Papers as Treatment of Choice at many National Meetings MIO implant

Difficult Fractures IMHS Implants

Reverse Oblique Pertrochanteric Subtrochanteric Comminuted Pertrochanteric Femoral Neck Fractures with subtrochanteric extension

Avenue for Simple treatment of difficult pertrochanteric hip fractures

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What Are Surgeons Willing to Accept for Reduction

A little bit of varus is OK, it will heal External rotation - better than internal rotation Shortening - Acceptable, They are household ambulators at best Achieve stability as soon as possible, then they can leave the hospital Polytrauma - need rapid stabilization

Difficulties with IM Hip Screws

Entrance site and nail configuration determine ultimate reduction Once entrance site made, difficult to change Common deformity is varus reduction Rotation, flexion / extension and shortening are frequent deformities Painful trochanteric bursitis - implant Salvage with osteotomy and plating

Revision Implants
Blade Plate - Abduction Osteotomy Proximal Femur Locking Plate Proximal Femur Hook Plate Revision I M Nailing - difficult with limited options once femur is reamed

Deformities from IMHS Devices

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Who needs Anatomic Hip Fracture Reduction

Elderly female with cardio-pulmonary issues with Hip Fracture? 60 year old active male cyclist? 45 year old female ? 30 year old motorcyclist Same Implant applied to all cases ?

Why the Blade Plate

Anatomic implant insertion is correct, anatomic reduction can be achieved Does not remove bone from proximal femur Can be loaded with tremendous compression Flexible implant - not rigid like locking plates

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Why the Blade Plate

If put in correctly - Anatomic Reduction Excellent revision implant for proximal femur and femoral neck malunion / nonunion Allows COMPRESSION and Loading ! Elegant surgery

Misconceptions of the Blade Plate

Difficult to use Only One chance to insert Not forgiving Flexion / Extension deformities Old implant resigned to hip osteotomy and history Not as easy as an IMHS

Internal Fixation of Hip Fractures

Should be flexible Rigid inflexible fixation fails Anatomic restoration of the bony anatomy restores hip balance and function The bone is the master of the soft tissues Correct hip mechanics only returns with anatomic reduction

Can the Blade Plate Deliver ?

Requires technical skills Choice of fracture table or free hand Use of distractors Once mastered, you become a member of the Blade Plate Club

Can manage extremely difficult proximal femur fractures

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Blade Plate as Revision Implant

It is the Hip Osteotomy Plate Multipli-plane corrections Compression implant Tension Band Implant

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Deformities
Varus Extension External rotation Shortening Axis malalignment
Removal of IMHS device and mobilization of fracture surgeon missed reaming the greater trochanter

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normal alignment axis correct

Reduction on fracture table with traction and Weber clamp derotation of fracture to correct alignment

Insertion of 950 fixed angled Blade Plate

Addition of Greater Trochanteric Cerclage Wiring

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Conclusions
IMHS not the answer for every hip fracture frequent malreduction Active, young, middle aged, and older do require anatomic hip fracture reduction Blade plate is an elegant simple implant malaligned in the past Proximal Plates as revision instruments

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