Journal Club on Unstable trochanteric fractures

1. Journal Club
Unstable trochanteric fractures: Issues
and avoiding pitfalls
Author:- Sushrut Babhulkar
Injury: 2017
Dr. Shubhanshu
Guide - Dr.John Mukhopadhaya

2. Introduction
• Trochanteric # : one of the most common hip
fractures in the elderly/ osteoporotic
• Occurs usually following low energy trauma.
• The incidence is rising :senior citizens,
osteoporosis

3. Introduction
• Goal: To return the patients to their pre-
fracture activity level early
• The incidence of complications remains high.

4. Introduction
Factor essential for the pre- op planning
• i) # geometry
• ii) Bone quality
• iii) comminution
• iv) # extensions to NOF # & subtrochanteric

5. Introduction
Following parameters contribute to inherent instability
and failure of fixation
• i) Loss of posteromedial support,
• ii) Severe comminution at the GT leading to difficulty
in passing an IM nail
• iii) Subtrochanteric extension of fracture
• iv) Reverse oblique fracture pattern
• v) Burst lateral wall
• vi) Posterior wall Fracture
• vii) Extension into femoral neck area,
• viii) Poor bone quality

6. Introduction
To minimise the risk of failure and necessity for
re-intervention:
• Appropriate selection of Implant
• Good reduction intraop
• Proper surgical technique from the surgeon’s
point of view

7. Review of literature
• 1948 Evans
Key to a stable fracture reduction is
restoration of the posteromedial cortical
continuity.

8. Review of literature
Dimon and hughston
(1967)
• Developed a technique
whereby the spike of the
proximal head neck
fragment is impacted
within the medullary canal
of the femoral shaft,
which previously was
displaced medially
beneath that spike.

9. Review of literature
1997 Baumgaertner et al.
Compared the results of
the surgical t/t of
trochanteric hip #
before and after
surgeons had been
introduced to the tip-
apex distance (TAD) as a
method of evaluating
screw position

10. Review of literature
Madsen et al.
concluded that the
trochanteric
stabilising plate
(TSP) may be an
aid in treatment of
these fractures

11. Review of literature
2001 Haidukewych
Cephalomedullary implant :- Shorter lever
arm and has less potential for the fracture
collapse and limb shortening when used for
unstable intertrochanteric #
2009 Haidukewych
Intramedullary nail fixation has become more
common, even for fractures that are stable or
nondisplaced

12. 10 simple tips to minimise failure and
improve outcomes when treating IT #
of the hip.
Measurement of the Tip to Apex distance;
No lateral wall: no use of hip screw;
 Know the unstable intertrochanteric fracture
patterns and nail them;
Beware of the anterior bow of the femoral shaft;
When using a trochanteric entry nail, start slightly
medial to exact tip of greater trochanter;
Do not ream an unreduced fracture;

13. Be cautious about the nail insertion trajectory
and do not use a hammer to seat the nail;
Avoid varus angulation of the proximal
fragment- Use the relationship between the
tip of trochanter and centre of femoral head;
When nailing, lock the nail distally if the
fracture is axially or rotationally unstable;
Avoid fracture distraction when nailing

14. Review of literature
2002 Sadowki et al.
• comparative study between dynamic condylar
screw (DCS) and PFN.
• Intramedullary nail had shorter operative
time, fewer blood loss and shorter hospital
stay compared with those treated with a 95
degree DCS.

15. Review of literature
• 2006 Babhulkar
Stable # with DHS but unstable #
with cephalomedullary implant to prevent
rotational instability
• 2006 Kulkarni et al.
DHS gold standard for treatment of stable
trochanteric # but unstable trochanteric # should be
treated with cephalomedullary implant

16. Review of literature
• 2010 Gupta et al.
• The combination of TSP and DHS creates a
biomechanically stable construction allowing
reconstruction of the lateral wall to maintain
adequate lever arm and abductor strength.

17. Review of literature
2013 Hsu et al
• Lateral femoral wall thickness. A reliable
predictor of post-operative lateral wall
fracture in intertrochanteric fractures

18. lateral wall thickness (d), defined as the
distance in mm from a reference point 3
cm below the innominate tubercle of the
greater trochanter, angled at 135 upward
to the fracture line (the midline between
the two cortex lines) on anteroposterior
radiograph.
A) preservation of adequate lateral wall
thickness when the fracture line passes higher in
the trochanteric region in . fractures, and B) the
lateral wall decreases and the posteromedial
section comminutes when the fracture line
passes lower in the trochanteric region, resulting
in fractures

19. Babhulkar’s Modification
Based on 3D CT reconstruction. Unstable
fractures are within the outline and then are
further subdivided into A,B and C subtypes.
Type A- Lateral trochanteric wall fracture as
seen on lateral CT. Type B- Posterior wall
fracture as seen on Posterior and Oblique CT.
Type C- Burst Lateral wall with posterior wall
fracture with Medial column (Lesser
Trochanter) dissociation and overall
Comminution

20. In the past there is several classification system
but recently lateral trochanteric wall fracture
gained importance
Unstable trochanteric wall fracture classified
into :-
 Posteriomedial comminution
 Reverse oblique
 IT # with Subtrochanteric extension
 IT # with detached GT and lateral wall
breech

21. Methodology
 A prospective study done from September 2014
to nov 2015 diagnosed unstable IT# on X-ray .
 Classified according to AO describe the fracture
pattern and measure taken to fix it
 Outcome measure using Harris Hip score
 Surgical procedure either DHS or PFN A2
 All fracture were stabilize with or without
trochanteric reconstruction
 Comminuted fracture fragments of GT reduced
with Loops (single or double)

22. outcomes
• Evaluated 86 patients up 6 months
• Mean age 68 years out of which 20% were
above 80 yrs
• Ten modalities of treatment were used
• The Harris hip score included

23. 1-4 days
5-10 DAYS
> 10 DAYS
Duration between injury and surgery.
2.34%
2.34%
28% 69.76%

26. Discussion
Factors influence outcome are
 age of patient,
 patient’s health,
 time from fracture.
The DHS implant, introduced by Clawson remains the
implant of choice
An intramedullary implant has the advantage of
 Control of axial telescoping stability
 rotational stability
 minimally invasive manner is better tolerated

27. • Intramedullary implants withstand higher
static and a several-fold higher cyclical
loading.
• Studies carried out by Saudan et al use of DHS
may allow more patients to return to their
previous level of activity.
• Pre-operative assessment on 3D CT
reconstruction aids in formulating a better
preoperative planning

28. • The Z-effect (werner et al.):sliding of the
proximal screws to opposite directions during
the postoperative weight-bearing period.
• The reverse Z-effect ( Boldin et al.).
• 70% of patients who underwent
intramedullary nailing showed fair to excellent
results.
• Complication rate is 11.62% .

29. . A 45 year old male,RTA, trochanteric fracture Modified AO/OTA type 31
A3.1.B

30. . c) Immediate Post-Operative X Ray. d) Post operative 3D CT

31. Take home message
• Augmentation techniques should be
considered.
• Fractures should be classified on the basis of
three dimensional computed tomography
• Lateral and posterior wall fractures , reverse
oblique need to be identified
• Intramedullary devices tend to give better
stable fixation