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Kyle F. Dickson, M.D. M.B.A.

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The Problem Distal Fixation Treatment Options Retrograde ... Difficult management Locked plates helpful Maintain principles of fracture management ... – PowerPoint PPT presentation

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Title: Kyle F. Dickson, M.D. M.B.A.


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Kyle F. Dickson, M.D. M.B.A.
Professor Baylor College of Medicine Southwest
Orthopaedic Group, Houston, Texas
2
Place of Revision Joint Replacement
  • Kyle Dickson MD, MBA
  • Professor Baylor College of Medicine
  • Southwest Orthopaedic Group, Houston Texas

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Arthroplasty
Trauma
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Peri-prosthetic Epidemic??
  • Increasing incidence
  • Prevalence arthroplasty
  • Graying of America
  • Increased lifespan
  • 1 rising diagnosis peri-prosthetic femur
    fracture (OTA, 2003)

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Challenges in Osteoporosis
  • Reduction reduction clamps or reduction screws
    pull out
  • Loss of reduction due to hardware failure
  • Sick and higher mortaliy
  • Soft tissue concerns

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Hip Fracture PATIENT Outcome Predictors
  • Pre-injury physical cognitive status
  • Ability to visit a friend or go shopping
  • Presence of home companion
  • Postoperative ambulation
  • Postoperative complications (Cedar,
    Thorngren, Parker, others)

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Treatment Goals
  • Restore axial alignment and length
  • Stable fixation
  • ROM as soon as possible
  • Maintain fracture enviroment suitable for boney
    healing
  • Return to pre-injury mobility
  • Op treatment best accomplishes these goals

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Classification
  • Undisplaced fracture
  • Prosthesis intact

Type I Type II Type III
  • Displaced fracture
  • Prosthesis intact
  • Displaced or Undisplaced fracture
  • Prosthesis loose

Lewis and Rorabeck (1997)
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VP
  • 50 yo MVA femur fx
  • EtoH
  • 1pk/day tobacco
  • Insulin dependent diabetic
  • gt20 yo hip fracture with increasing hip pain
    seeking medical intervention

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  • Options?

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Treatment Options (type?)
  • Anterior plating conventional vs locked (leave
    DHS)?
  • Plating (remove DHS)?
  • IM nail ante vs retro (remove DHS)?
  • THA and plate?
  • Other options?

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Biomechanical Evaluation of the LISS, Angled
Blade Plate, and the Retrograde Intramedullary
Nail for the Fixation of Distal Femur Fractutres
An Osteoporotic Cadaveric ModelKregor OTA 2002
  • Osteoporotic cadaveric femuri (age 70 yo)
  • Tested to failure in axial loading and torsion
  • Axial loading 34 higher load for LISS Vs blade
    plate and 24 higher than IMN
  • Loss of distal fixation with CBP and IMN
  • Plastic deformation with LISS and no loss of
    distal fixation
  • Torsion strength same for CBP, but higher for IMN

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Evolution
Or something completely different?
You be the judge!
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Any other studies?
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Treatment
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Plating Technique?
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Comments?
  • Type of plate?
  • gt300 LISS no hardware failures 2 surgeon errors
  • gt50 locking condylar 7 hardware failures (surgeon
    error?)

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FU 1 1/2 yr
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Periprosthetic Fracture
58 y.o. female s/p multiple revisions R THA low
energy fall
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Periprosthetic Fracture
-ORIF articular component - CR LISS plate shaft
- circlage cable prosthesis
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Periprosthetic Fracture
58
Case
  • 64 yo with no real pain prior to a fall
  • Previous hip surgery for AVN 20 years ago

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Questions
  • Stem loose?
  • Cup loose?

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Options
  • Revise both cup and stem?
  • Cerclage fractures around stem with a plate?
  • Revise just the femur to long stem implant with
    cerclage wires?
  • Revise femur and use plate (type?)?
  • Other tests?

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Case
  • Elevated C-reactive protein and ESR (wbc nl)
    staged removal and cultures and traction (cement
    spacer?)
  • Scanogram bilaterally

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The Problem
Distal Fixation
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Treatment Options
  • Retrograde intramedullary nail
  • Conventional plating (blade plate)
  • Locked plating
  • Revision with stemmed prosthesis, allograft, or
    tumor prosthesis

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Biology and BonePreserve the periosteum
  • Evolution
  • DCP
  • Large footprint, frictioned to bone
  • LCDCP
  • Smaller footprint, still frictioned to bone
  • LCP
  • Point contact with bone, no frictioning

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Direct Reduction
  • fracture manipulated with bone-holding forceps or
    levers
  • negative biologic impact

Choke Kill
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15 months post-op
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77 yo F with femur nonunion
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Retrograde Nailing
  • Is the notch open or closed?
  • If open, is it large enough?
  • Narrow notch and closed box seen in posterior
    stabilized knees

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Summary - Nails
  • Know the characteristics of the nail you use
  • Consider curve mismatch
  • Avoid anterior cortex impingement
  • Consider longer nails than shorter
  • Consider Locking distally
  • Pending data!

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Retrograde Intra-medullary Nail
  • Nail size canal diameter mismatch
  • Must have two interlocking screws distally

83
Constrained Rotating Hinge
84
Constraint Comes at a Price!!
Peri-prosthetic fracture
Non union and broken plate
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Inter-Device Distance (IDD)
lt12cm
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Interprosthetic Fractures
  • Similar principles
  • Overlap stems when present
  • Avoid retrograde nail
  • Stress concentration between nail and THA
  • LISS for distal fractures

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Summary
  • If prosthesis is looseRevise it
  • If bone is missing.Graft it or strut it
  • If prosthesis is stable...Fix the fracture
  • Strut grafts not necessary
  • Locked plates are better than standard plates
  • Locked plates better than retrograde nails
  • Splint the entire bone..the longer the better
  • Overlapdont gap!

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Summary - patient
  • Periprosthetic fracture are a growing epidemic
  • Fractures are difficult manage
  • Patients may be difficult to manage
  • Team approach
  • Consider functional goals for patient
  • Consider skill of the surgeon

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Summary screws and surgery
  • Screws better than wires
  • Locked screws better than standard screws
  • Bicortical locked screws better than unicortical
    locked screws
  • Use indirect reduction techniques
  • Use biologic, atraumatic surgery

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Conclusion
  • Periprosthetic fracture are a growing epidemic
  • Difficult management
  • Locked plates helpful
  • Maintain principles of fracture management

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Thank You
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