Kyle F. Dickson, M.D. M.B.A. - PowerPoint PPT Presentation

About This Presentation
Title:

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

Description:

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

Number of Views:126
Avg rating:3.0/5.0
Slides: 82
Provided by: Donna481
Category:

less

Transcript and Presenter's Notes

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


1
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

3
Arthroplasty
Trauma
4
Peri-prosthetic Epidemic??
  • Increasing incidence
  • Prevalence arthroplasty
  • Graying of America
  • Increased lifespan
  • 1 rising diagnosis peri-prosthetic femur
    fracture (OTA, 2003)

5
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

6
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)

7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
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

16
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)
17
(No Transcript)
18
VP
  • 50 yo MVA femur fx
  • EtoH
  • 1pk/day tobacco
  • Insulin dependent diabetic
  • gt20 yo hip fracture with increasing hip pain
    seeking medical intervention

19
(No Transcript)
20
(No Transcript)
21
  • Options?

22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
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?

27
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

28
Evolution
Or something completely different?
You be the judge!
29
Any other studies?
30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
Treatment
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
Plating Technique?
42
Comments?
  • Type of plate?
  • gt300 LISS no hardware failures 2 surgeon errors
  • gt50 locking condylar 7 hardware failures (surgeon
    error?)

43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
FU 1 1/2 yr
50
(No Transcript)
51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
Periprosthetic Fracture
58 y.o. female s/p multiple revisions R THA low
energy fall
56
Periprosthetic Fracture
-ORIF articular component - CR LISS plate shaft
- circlage cable prosthesis
57
Periprosthetic Fracture
58
Case
  • 64 yo with no real pain prior to a fall
  • Previous hip surgery for AVN 20 years ago

59
(No Transcript)
60
Questions
  • Stem loose?
  • Cup loose?

61
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?

62
Case
  • Elevated C-reactive protein and ESR (wbc nl)
    staged removal and cultures and traction (cement
    spacer?)
  • Scanogram bilaterally

63
(No Transcript)
64
(No Transcript)
65
(No Transcript)
66
(No Transcript)
67
(No Transcript)
68
(No Transcript)
69
The Problem
Distal Fixation
70
(No Transcript)
71
(No Transcript)
72
(No Transcript)
73
Treatment Options
  • Retrograde intramedullary nail
  • Conventional plating (blade plate)
  • Locked plating
  • Revision with stemmed prosthesis, allograft, or
    tumor prosthesis

74
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

75
Direct Reduction
  • fracture manipulated with bone-holding forceps or
    levers
  • negative biologic impact

Choke Kill
76
(No Transcript)
77
15 months post-op
78
77 yo F with femur nonunion
79
(No Transcript)
80
Retrograde Nailing
  • Is the notch open or closed?
  • If open, is it large enough?
  • Narrow notch and closed box seen in posterior
    stabilized knees

81
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!

82
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
85
Inter-Device Distance (IDD)
lt12cm
86
Interprosthetic Fractures
  • Similar principles
  • Overlap stems when present
  • Avoid retrograde nail
  • Stress concentration between nail and THA
  • LISS for distal fractures

87
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!

88
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

89
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

90
Conclusion
  • Periprosthetic fracture are a growing epidemic
  • Difficult management
  • Locked plates helpful
  • Maintain principles of fracture management

91
Thank You
Write a Comment
User Comments (0)
About PowerShow.com