Fractures of the Femoral Neck and Intertrochanteric Fracturs：股骨颈骨折和股骨粗隆间骨折

FracturesoftheFemoralNeckandIntertrochantericFracturesKnutStrömsöe,MDPhD,OrthopaedicDepartment,AkerUniversityHospital,Oslo,NorwayClassificationoffracturesintheproximalfemurTheComprehensiveAO/ASIFClassification(Mülleretal.1990)offracturesintheproximalfemurThecomprehensiveclassificationofneckfracturesoftheproximalfemurPauwel’sclassificationofneckfractures(1965)(basedontheanglethefracturelinewiththeresultantofforces(R))Garden’sclassification

(basedontherelationshipofthemedialtrabeculaeintheheadandpelvis)Reportedannualincidenceofhipfracturesper100000ofpopulation(ParkerandPryor1993)Sweden 165Canada 103Finland 91UK 86USA 80Malayasia 70Israel 59Korea 34

population40000001979:68001989:99001999:11800(290per100000)NumberofhipfracturesinNorway1979-1999:

Wehavetodefineourproblem

Aging219001930196019901997200020202050CooperC,CampionG,MeltonLJ(1992)OsteoporosisInt;2:285-2896.25millionisanestimatednumberofhipfracturesworldwideby2050Increasingworldpopulationandincreasinglifeexpectancyseemstobethemostimportantreasonforthisincrease

Whydoweexperienceanincreasethenumberoffractures?

FallingfrequencyincreaseswithagePorosityofboneincreaseswithageCooperC,CampionG,MeltonLJ(1992)OsteoporosisInt;2:285-289Determinantsoffracturerisk-Neuromuscularfunction-Environmentalhazards-TimespentatriskTypeoffallProtectiveresponsesEnergyabsorptionGeometryofboneBonemineralmassQualityofboneRiskoffallForceofimpactStrengthofboneRiskoffracture

ChoiceofTreatmentpolicyGradeofdislocation(Garden1972,Thorngren1991)Sizeofheadfragment(Benterudetal.ActaOrthScand1994)Posteriorcomminution(Benterudetal.1997)Osteoporosis(Bentley1972,Riska1969,Anderson1969,Thorngren1995)

Fracturerelatedpatternoffemoralneckfracturesrepresentingriskforosteofixationfailure,non-unionandavascularnecrosisImpactedfracturesarereportedtohavelessincidenceofnon-unions(BentleyG,JBJS;50B:551,1968,Raymakers,1993)Impactedfracturesdeveloplesssegmentalcollapseinavascularnecrosisofthehead?

Fracturerelatedpatternoffemoralneckfracturesleadingtoa“treatmentpolicy”..Crawfordreported12%ofavascularnecrosisin50impactedfracturesoutof339femoralneckfractureswithanoverallincidenceofavascularnecrosisin37%(CrawfordH,JBJS;47A:830,1965)Preservationofthefemoralhead

orhemi(total)arthroplasty?JuliusNicolaysen(1831-1909),fromBergen,workedasaProfessorinOslo.Henailedamedialfemoralneckfracturein1893,2yearsbeforeWilhelmKonradRøntgendiscoveredtheX-rayOsteoporosisisfrequentnotthemainproblemFracturepatternisoftendifferentastotheolderpatientProstheticreplacementasaprimarytreatmentalternativehastobechosenwithgreatercarethanintheolderpatient

Femoralneckfracturesintheyoungor“younggeriatric”patienthavedifferentaspectsastotheolderpatient..

Transcervicalandsubcapitalfemoralneckfracture(31Band31-C3)inthe“younggeriatric”patientHipreplacement(hemiortotalarthroplasty)representsaninternalamputationwithallitsimplicationsPreservationofthejoint(asinalljointfractures)shouldbewhatweaimatinthetreatmentSecondaryfailureslikesecondaryosteofixationfailureaswellassegmentalcollapsemaybehandledbysecondaryarthroplasty

“PrimaryandsecondaryCharmley-Hastingshemiarthroplastyindisplacedfemoralneckfracturesandtheirsequelae”BenterudJG,KokWL,AlhoA.In:AnnChirGynaecol1996;85(1):72-6Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?Functionallytreated:No.ofPatients Age Instable59 15-69 2=3%73 70-94 16=22%Raaymakers1993Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?Intheliteraturewefind:Instability:Afterearlymobilisationwithoutweightbearing:8-19%Afterimmediatefullweightbearing:32-65%Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?Mortalityinimpactedfemoralneckfractures:Operativetreatment>10%Conservativetreatment1.8-3.3.%(Raaymakers1993)Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?

Retroversionisnotanimportantreasonforhigherinstability(Raaymakers1993)“Itisimpossibleatthetimethepatientpresentshimselftopredictwhichfractureswillundergodesimpaction”(Bentley,Crawford,Judet,Asser,Hansen,Famos,Jeannaret)Whatdowedowiththeimpactedfemoralneckfracture(31-B2)?

Conclusionmaybeasfollows:Agelessthan70:

Internalfixationin situAgemorethan70:Conservativetreatment.If secondarydislocationor AVN:ArhroplastyTimingofSurgeryIndislocatedfemoralneckfractures..

Aspreservationofthefemoralheadisthemaingoalofourtreatmentsurgeryshouldbeperformedassoonaspossibleandlatestwithin6hoursThevalueofdecompressionoftheintracapsularhaematomastillisunknownTimingofSurgery.Ifnotimmediate?Indislocatedfemoralneckfractures..

ThevalueofimmobilisationintractionisquestionableinconcernofdevelopmentofavascularheadnecrosisPositioningofthehipinthemostcomfortablepositiontothepatientprobablyalsoisthepositionwheretheintracapsularpressureisatlowest

Istheviabilityofthefemoralhead

predictable?

Byfractureclassification?Byscintigraphy?MRIIntraoperativebybleeding?Intraoperativebymeasuringofelectricpotentialwithtemporaryimplantedplatineelectrodesandgasinsuflation(H2O2)?Preoperative

IntraoperativeInfemoralneckfractures..

Istheviabilityofthefemoralheadpredictable?MRI

ReductiontechniqueinintracapsularfracturesofthefemoralneckLoosenthefractureby“unpack”itAfterhavingobtainedthereduction“packthefracture”andthenfixitMarkFlynninjury1973ImpactedfractureNondisplacedfracture

DisplacedfractureReductionmanoeuvre(Leadbetter)ImpactedfractureIntracapsularfracturesofthefemoralneckInternalrotationofthefootshouldresultinthefemoralhead,neckandshaftallappearinginastraightlinewithnoresidualanglulationatthefracturesitedorsalventral

ChoiceofImplant

ChoiceofImplant

CannulatedbonescrewsNoncannulatedbonescrewsNailswithhooks(Hansennails)1300AnglebladeplateSlidingScrewPlateSystems(DHS,HCS)

Implantdemands..Theimplantshallprovidestability-preventdislocationinvarus-preventdislocationinretroversion-preventrotationalmicromovementsAllowaxialsinteringalongtheimplantwithoutpenetratingintothejointIncaseofdelayedunionandnonunionmigrationintothejoint/pelvisshouldnotbepossibleChoiceofImplant:

SlidingScrewPlateSystemChoiceofImplantBenterudJG,HusbyT,NordslettenL,AlhoA:“FixationofdisplacedfemoralneckfractureswithaslidingscrewplateandacancellousscrewortwoOlmedscrews.Aprospectivestudyof225elderlypatientswitha3-yearfollowup”.AnnChirGynaecol1997;86(4)338-42ChoiceofImplantAnnChirGynaecol1997;86(4)338-42Conclusions. Bothtreatmentmethods resultedinhighrateofosteofixation failures(18.5%intheSSPgroupand19.5%intheOlmedgroup)andnon-unions(6.2%and8.5% respectively)ChoiceofImplantIn31-B2fracturesofthe“younggeriatric”patienta4holeDHSwithanantirotationalscrew,however,istheimplantofchoice.ThefixationonthetensilesideofthefemurandglidingcylinderforthescrewprovidesstabilityovertimeChoiceofImplantAnglebladeplateandcancellousscrewFemoralneckfractures:

Ifscrews:Twoorthreescrews?Positionofthescrews?Dimensionsofthescrews?

ThreescrewfixationtechniqueinfixationofcervicalfracturesoftheproximalfemurChoiceofImplantScrewswithheadandwasherpreventingaxialmigrationininstabilityScrewswithoutheadandequaldiameterofthreadandshankFateofthemedialneckfractureafterORIFEarlyosteofixationfailurein8-16%Non-unionin8-10%AVNin6-10%

Thismakesanoverallfailurerateof20-30%but-inthefirstyearafteramedialneckfracture25%ofthepatientaredeadtounrelatedfracturedeseaseClassificationoftrochantericfractures(31-A1-3)Bonemassrelatedtoageincancellousboneandcorticalbone100years50yearsBonemassTrochcantericarea

NeckofthefemurAgeFracturesintheproximalFemuratAkerHospital,Oslo,Norway1999

Diagnose No MedianagemalefemaleCervicalFrx 28284(29-104)53229PertrochantericFrx 18688(54-102)75111SubtrochantericFrx37 86(39-95)2017505148357BiomechanichsoftheproximalfemurBiomechanichsoftheproximalfemurBiomechanichsoftheproximalfemurFracturepatternreflectsbiomechanichs

oftheproximalfemurindifferentstagesbyfallingFallingactivatestensileforcesofthemusclesFallinginducesrotationofthefemuronthefixedlegForcesactonthetrochanterbydirectcontactattheendofthefallInunstabletrochantericfracturesintheelderlytheimplantchosenhaveto:respecttheinstabilityofthefractureallowfractureimpactionduringmotionwithoutfixationfailuresecureretentionofthefractureinacceptablepositionduringhealingbuildabiomechanicalconstructwiththeboneallowingearlyweightbearing31-A3.3Fracture.DHSandTSPWeek8Week0slidingscrew-platesystemallowingthefracturesinteringplateonthetensilesiteneutralisingtensionforcesTrochantericSupportingPlatepreventingfemoralshaftmedialisationAdditionalantirotationalscrew31-A3.3Fracture.,The

-nailslidingscrew-nailnailinthecentreofthefemoralaxisreductionoftheleverarmnoneutralisationonthetensilesidesinteringinvaruswith“cuttingthrough”31-A3.3Fracture.The

-nailDay1Day126Day160Inunstabletrochantericfracturesintheelderlytheimplantchosenhaveto:respecttheinstabilityofthefractureallowfractureimpactionduringmotionwithoutfixationfailuresecureretentionofthefractureinacceptablepositionduringhealingbuildabiomechanicalconstructwiththeboneallowingearlyweightbearin