rt op ed i Subtrochanteric Fractures Current Conceps and Outcomes ya O Uğur GÖNÇ, MD Ç an ka Çankaya Hospital Dept. Orthopedics and Traumatology Ankara, TURKEY AO Trauma Advanced Course Krakow, 2014 ed i Learning Outcomes op • Definitions rt • Fracture anatomy Ç an ka – Scientific basis – Decision making ya • Plating or nailing ? O • Proximal femur biomechanics Proximal border NS DBLT Fielding (1966) PBLT NS 2 10 cm > 10 5 cm 4 NS 4 Zickel (1976) PBLT 10 cm 6 Seinsheimer (1978) O Cech and Sosa (1974) rt Watson, et al (1964) No. of subdivisions NS op Boyd and Griffin (1949) Distal border ed Study i Classification Systems DBLT 5 cm 7 DBLT 5 cm 4 NS NS 3 BLT 5 cm 6 NS NS 5 NS NS 3 AO Müller (1990) DBLT 3 cm 9 Wiss and Brien (1992) DBLT 7.5 cm 3 Parker and Pryor (1994) DBLT 5 cm ya Pankovich, et al (1979) Harris (1980) Malkawi (1982) Ç an Russell and Taylor (1987) ka Waddell (1979) NS = Not stated; PBLT = proximal border of lesser trochanter; DBLT = distal border of lesser trochanter. Ç an ya ka op rt O ed i Definition ed i Comprehensive Classification O rt op 32 A Ç an ka ya 32 B 32 C Difficult to restore medial support ed i Fracture Anatomy Ç an – Adductors  ka • Distal fragment O rt flexion varus ext. rotation ya    – Iliopsoas – Hip abductors – Ext. rotators op • Proximal fragment adduction shortening op ed i Fracture Anatomy ya O rt Understanding the fracture pattern and deformity Ç an ka Counteract deforming forces during fracture reduction and fixation O rt op ed i Biomechanics Ç an ka ya Tensile forces Compressive forces ed i Biomechanics & Ç an ka ya O rt op High bending loads Lack of medial support ed i Biomechanics ya O rt op Implications for upper femoral implants Ç an ka Mechanically strong Tolerate bending forces ed i Current Treatment Options op • Conservative / traction ka Ç an – Plates – IM nail O ya • Internal fixation rt • External fixation ed i Plating O rt op n = 337 sliding hip screws (SHS) Overall failures: 8% Ç an ka ya n = 111 dynamic condylar screws (DCS) Overall failures: 14% n = 130 angular blade plates Overall failures: 20% Ç an ya ka op rt O ed i ORIF ed i Locking Plates Ç an ka ya rt O • Plate and screw breakage op • No enough studies ? i ed op 17% nonunions 0% nonunions Ç an ka ya O • 23 ORIF (pre 1981)  • 24 indirect reduction  rt n = 47 Plates perform well with less invasive surgical technique Ç an ya ka op rt O ed i MIPO ed i IM Nailing • Parmer MJ. Injury. 28(2): 91-5, 1997 op – n = 180 rt – Overall failures  5 % O • Wıss DA. Clin Orthop Relat Res. 283:231-6,1992  3% Ç an ka – Overall failures ya – n = 95 ed i IM Nails Cephalomedullary Troch. entry Ç an ka ya O rt op Centromedullary Standart interlocking Blade Recon. screws i ed rt op ka ya O n = 102 (1999-2005) FU 60/102 (%60) 19 fractures in varus  100 Complications – 3 nonunions – 2 nail breakage – All in varus group (20% failure) Ç an • • • • Ç an ka ya O rt op ed i Varus Malreduction Ç an ka ya O rt op ed i Flexion Deformity ed i Entry Point op • Piriformis entry rt • Trochanteric entry ya O – Just medial to tip – 1/3 ant – 2/3 post ka • Lateral entry  varus Ç an • Nail does not help reduction ed i Reduction Tools op • Mallet O rt • Bone hook ya • Ball spike pusher ka • Shanz screw Ç an Till the end of reaming !!! ed i Blocking Screw op • Flexion O rt – Posterior – Lateral  medial • Varus Ç an ka ya – Medial – Anterior  posterior ed i Open Reduction op • Percutaneous – Colinear clamps O rt • Mini-open • Cerclage cables ya – Bone calmps Ç an ka – Long oblique-spiral fractures – Percutaneous passer op ed i 2007 O rt Complications of 66 patients with comminuted subtrochanteric fractures RTRN Group (n = 34) DCS Group (n = 32) Superficial wound infection 1 2 Delayed union 0 1 Implant failure 1 0 Ç an ka ya Variables i ed op versus Plates Ç an ka ya O rt Nails Ekstrom 2007 Miedel 2005 Sadowski 2002 Pooled RR 0.29 (0.06-1.33) JOT, 2009 Ç an ka ya O rt op ed i Plate or IM Nail ? i ed op Ç an ka ya O rt Type of Implant ? ed i Choice of implant general considerations ka Biologic plating technique Ç an • ya – No medial hinge integrity rt Strong and long enough O • op Plates ed i Choice of implant general considerations op Nails Long nails • Locking options ya O rt • Ç an ka – Standart locking  intact lesser tr. – Reconstruction options O rt op Bone quality ed i Surgical Desicion Making Ç an ka ya Fracture pattern ed i Bone Quality op • Poor bone quality Ç an ka ya O rt favors IM nails ed i Fracture Pattern Ç an ka may favor plating ya • Trochanteric extension rt good options O • Plates and nails are both op “Simple” fractures ed i Fracture Pattern • Plating Ç an ka ya – Strong plate – “Biological” techniques O rt • Favor nailing op “Complex” fractures op ed i Take home messages Ç an ka ya O rt Understanding the fracture anatomy and inherent deformity is key to success in fracture reduction and fixation ka ya O rt op Eccentric mechanical loading of the upper femur ed i Take home messages Ç an Strong implants ed i Take home messages op • IM nailing O rt – Long nail is a safe option – Avoid malreduction • Plating Ç an ka ya – Perform less invasive techniques