Kyle F. Dickson, MD MBA

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Kyle F. Dickson, MD MBA
Professor Baylor College of Medicine Southwest
Orthopaedic Group, Houston, Texas
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Femur Fracture Management Update

• Kyle Dickson MD, MBA
• Proffessor Baylor College of Medicine
• Southwest Orthopaedic Group, Houston

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gt5000 trauma admits with gt1800 patients with
ISSgt15 (1 ACS)
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EF

• 40 yo in MVA
• R open femur fracture, L open tibia, R patella
• R femoral neck, R Transverse
• R rib fractures with a hemothorax
• Splenic and liver laceration
• SBP 88, HR 136, intubated

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EF

• BD 6 meq/l
• Temp 33

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Coagulopathy

• Hypothermia
• ? Ca2 (blood citrate)
• Acidotic
• Lethal Triad hemorrhage, coagulopathy,
  inflamatory/metabolic

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Coagulopathy Trauma

• By the time of arrival at the ED, 28 (2,994 of
  10,790) of trauma patients had a detectable
  coagulopathy that was associated with poor
  outcome (MacLeod et al., 2003)

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INR vs Mortality 1st 24 hrs in STICU
P 0.02, ROC 0.71
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Hemostatic Resuscitation
1U PRBC 1U FFP 1U Plts 1U Cryo
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When?
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TOO SICK NOT TO FIX FRACTURES
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ORDER OF FIXATION

• Most important - femoral neck
• Most necessary shaft
• Most expertise - acetabulum

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Morshed JBJS 2009

• Relative risk of mortality treatment weighted
  analysis
• Delay gt 12 hours for femoral shaft stabilization
  ? mortality 50 (especially serious abdominal
  injury)

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Problems

• Assumption is that delay is random not that the
  patient is being stabilized
• The weighting corrects for illness but not
  results of treatment and stabilization parameters
• ? Ex fix until patient stabilized

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Problems

• Fixing femur fractures may have nothing to do
  with mortality but delay in fixation may be
  sicker patients selection bias
• Significant ? in mortality12-24h, 48-120h and gt
  120 h - ? Not 24-48 h

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Problems cont.

• Trauma registry garbage in garbage out
• ? Ex fix until patient stabilized
• Assumption is that delay is random not that the
  patient is being stabilized

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Problems cont.

• Inclusion was same day transfers (? 11pm 1am)
• The weighting corrects for illness but not
  results of treatment and stabilization parameters

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Our Study

• Previous mortality of bilateral femur fractures
  50 recently 25.9 (11.7 for unilateral femur
  fracture)
• 6.7 (102/1519) mortality unilateral
• 20.0 (15/75) mortality bilateral

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Our Study cont.

• Multivariate logistic regression not significant
  for femur fractures
• Highly significant for age group, pedestrian
  accident, and ISS group
• ?fixed when stabilized and temporary ex fix

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Damage Control
Bilateral femoral ex fix, tibial ex fix and ID
at the bedside
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Damage Control Surgery

• Philosophy
• Stay out rather than get out of trouble
• Restore normal physiology at the expense of
  normal anatomy

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Topic Outline

• What do we know?
• The benefits of resuscitation
• The vast majority of patients benefit from early
  definitive long bone stabilization
• IM nailing of long bones has systemic effects

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Topic Outline

• Occasional patients are hurt by long bone nailing
• There is a systemic inflammatory response to
  major trauma

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Topic Outline

• Occasional patients are hurt by long bone nailing
• There is a systemic inflammatory response to
  major trauma

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Topic Outline

• What is unknown?
• How to predict bad consequences of long bone
  nailing
• The optimal timing of fracture repair for all
  patients

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Topic Outline
The benefits of temporary external fixation
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The benefits of resuscitation

• Uncompensated shock gross signs of circulatory
  deficiency (BP, HR, UO)
• Compensated shock ongoing suboptimal tissue
  perfusion
• The heart and brain are protected while the
  perfusion of other organs is inadequate
• Resuscitation - tissue acidosis eliminated and
  aerobic metabolism restored

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The benefits of resuscitation

• Lactic acid
• Endpoint of anaerobic glycolysis from poor
  tissue oxygenation
• Good approximation of the magnitude of
  hypoperfusion and shock

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Retrospective data from the 1980sEarly fracture
fixation is good!
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Bone and Johnson JBJS 1989

• Parkland hospital 178 patients with femur
  fractures randomized to before 24 hours or
  after 48 hours
• Patients with ISS gt 18 less pulmonary
  complications (ARDS, FE, pneumonia)
• Severely injured patients benefit the most!!

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Why does early fracture stabilization help the
lungs??

• Reduce continued marrow emboli
• Reduce pain and narcotic requirements
• Eliminates traction and supine positioning
• Less atelectasis and decreased pulmonary venous
  shunting

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Primary IM femur fixation in MTP with associated
lung contusion a cause of ARDSPape et al JT
1993

• 106 pts with femur fracture and ISS gt 18
• In patients with chest trauma nailing within 24
  hours led to greater ARDS (33 vs 7.7) and
  mortality (21 vs 4)

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Controversy IllustrationOTA 2005 and JOT
2006R. Meek Vancouver

• DCO vs primary nailing not much difference
• I prefer primary nailing

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The vast majority of patients benefit from early
definitive long bone stabilization

• Retrospective studies
• Prospective Bone and Johnson 1989
• Early femoral fixation leads to
• Less complications
• Less ICU
• Less cost
• Better outcome for the limb
• There is no debate!!

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IM nailing of long bones has systemic effects

• Robinson et al JBJS b 2001
• Trans esophageal echo and invasive monitoring
  during IM nailing
• Increase in PA pressure
• Decrease in arterial oxygen partial pressure
• Systemic change in markers of coagulation

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Systemic Effects of Nailing

• Brundage et al JT 2002
• 1362 patients over 12 years
• Femur fixation lt 24 hours - improved outcome even
  with severe chest and head injuries
• Resuscitation and hemodynamic normalization are
  essential parts of our protocol
• Only 65 of patients were physiologically ready
  within 24H
• Highest incidence of ARDS in group fixed between
  2 and 5 days - a time of heightened inflammatory
  response?

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There is a systemic inflammatory response to
major trauma

• Injury activates cell defense mechanisms,
  producing mediators of coagulation and
  inflammation
• Protect against infection
• Remove damaged tissue
• Initiate repair
• However severe inflammation my lead to organ
  injury

Good!!
Bad!!
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The pro inflammatory response is increased by
primary IM nailing

• Pape et al JT 2003
• Prospective study - 35 patients
• The systemic inflammatory response measured by
  IL-6 was increased (55pg/ml-254pg/ml) by
  immediate IM nailing but not by ex fx and
  secondary nailing
• No difference in clinical outcomes

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• 1st hit (trauma)
• FES
• SIRS
• 2nd hit (Surgery, infection, more FES)
• ARDS
• MODS
• MOF
• MSOF

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Occasional patients are hurt by long bone nailing

• Robinson et al JBJS b 2001
• 8/84 patients develop post op pulmonary
  compromise (7 were prophylactic for metastatic
  disease)

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Can we detect a patient at risk??

• Injury factors - High ISS, pulmonary injury,
  severe abdominal injury, bilateral femur or other
  multiple long bone injuries
• Physiologic factors Slow difficult
  resuscitation, high transfusion requirement,
  prolonged surgical time, hypothermia, coagulopathy

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Can we detect a patient at risk??

• Genetic and biochemical markers Currently not
  practical or reliable
• IL-6 (gt 800 pg/ml) - most studied and best
  correlates with outcome but .

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• DCO external fixation
• -Stabilizes orthopedic injuries while physiology
  improves
• -Avoid a second hit by major orthopedic
  procedures
• -Fracture stability without increased
  inflammatory response

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The benefits of temporary external fixation

• DCO - Retrospective cohort studies (Pape et al J
  Trauma 2002)
• -Significant reduction in systemic complications
• -No increase in local complications

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Damage Control Orthopaedics

• Prevent 2nd hit (MOF, MSOF, SIRS, ARDs)
• Hgb lt 8
• Base Deficit gt 5 mEq/l
• Body temperature lt 33º
• INR gt 1.5 (2.0 50 mortality)

Fix the femurs and the tibia within 48 hours
(lung)
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Timing

• Within 24-48 hours injuries most mobile
• 2-5 days may be worst time to operate
• Soft tissue good (includes lung)
• Positive fluid balance

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Exchange to an IM rod safe?
Bhandari et al JOT 2005 -Pooled data from level
4 studies -Average infection rate 3.6
Pin drainage
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Associated InjuriesMRI Study

• 70 intraarticular abnormality
• 26 ACL or PCL
• 41 meniscal injury Dickson JOT 2002
  
  
  

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Associated Injuries (cont.)

• 71 collateral ligament injury
• 30 tibial bone contusion
• 63 femoral bone contusion Dickson JOT
  2002

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Antegrade Femoral Nailing

• Table vs freehand?
• Supine vs lateral?
• Tools to help reduce the fracture

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Modern Nailing

• Guide rod centered in both planes with a
  stab incision 1.5-2cm depending on the fat 4-7cm
  above the tip of the trochanter
• Reduction prior to nailing except lateral
  displacement can be easily reduced with nail in
  proximal segment
• Examine patient immediately postop rotation
  position correct

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Modern Nailing cont

• Mobilization the same day or the day after with
  moving the leg within hours of the surgery
• Damage control orthopedics do not marrow nail in
  shock and do not continue reduction attempts
  and nailing over more than 1 hour

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Fracture Table?
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Fracture Table

• Problems
• Pain (15-20 minutes)
• Limitation of motion
• Limitation of radiographs
• Limited access in multiple trauma patients

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Fracture Table Problems cont.

• Pudendal, femoral, and sciatic nerve palsy (too
  much traction)
• Perineum wound
• Compartment syndrome (ipsilateral traction,
  contralateral need well padded leg)

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Fracture Table cont.

• Benefits
• Closed Reduction
• Stable platform (less mobility)
• Traction (femoral distracter)
• Less assistants
• Proximal femur fractures

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Freehand

• Quicker setup
• Easier reduction (more motion)
• Less stability of fracture (need assistance)

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Freehand cont

• Multiple injury sites with multiple teams
• Ipsilateral knee or ankle injury
• Retrograde nail

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Position?
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Position

• Surgeon dependent
• Lateral- easier piriformis fossa starting hole
• Supine- Greater trochanter starting hole
  (percutaneous piriformis starting hole difficult
  in supine position)

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Position

• Surgeon dependent
• Lateral- easier piriformis fossa starting hole
  (Kuntscher)
• Supine- Greater trochanter starting hole
  (percutaneous piriformis starting hole difficult
  in supine position)

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Positioning

• Traction
• Supine
• Lateral
• Supine No Traction
• Free Hand
• Femoral Distractor

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Position cont.

• ? Increased malunions with lateral position
• Good technique blocking pins for proximal and
  distal femur fractures
• Check femoral anteversion for malrotations

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Quebec ORIF L Hip
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Quebec ORIF L Hip
Lateral entry nail or straight nail through GT?
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Quebec ORIF L Hip
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Fracture table or radiolucent table

• Supine or decubitus possible on each
• Easier access to piriformis fossa in decubitus
  but
  difficult to control coronal plane
  angulation
• Set up quicker on radiolucent but
  
  requires
  more assistants
• Length difficult to regain late - Femoral
  distractor

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Tit. vs SS cont.Biomechanics

• Modulus of elasticity less stiffness (tit. 50
  less than SS but 5X greater than cortical bone)
• Fatigue strength tit. gt ss unless notched
  (tibia gt femur)
• Yield strength (screws lt 4 mm)

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Titanium vs SS

• Biocompatibility (pain bone formation.
  ?extraction)
• Imaging (femoral shaft and knee injury)
• Infection
• Cost 30 greater cost now canulated titanium
  bar stock

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Greater Trochanter Entry Point vs. Piriformis
Entry Point on Femoral Nails
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CAN YOU TEACH AN OLD DOG A NEW TRICK?
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Antegrade Femoral Nailingstarting point
Posterior - loss of proximal fixation
Piriformis fossa- proper starting point
Anterior - generates huge forces, can lead to
bursting of proximal femur
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Piriformis

• Straight shot
• Less damaged to abductor
• Fractures into piriformis fossa
• Harder to find

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Piriformis Pitfalls

• Too much adduction (perineal post) varus
  deformity
• Missing the entry point (supine vs lateral) blow
  out medially

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Piriformis Fossa Starting Point

• Piriformis Fossa Decreases Proximal Femoral
  Stress
• In line with Canal in AP M/L planes

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Terminal Subsynovial (retinacular) vessels
Superior Mixed type
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Posterior Aspect Femoral Neck
anterior
OE
Perforates the hip capsule and reaches the
synovial fold
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Posteromedial Nail Insertion
Dora C, et al., JOT, 15488, 2001.
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Greater Trochanter Starting Point
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Greater Trochanter

• Easier
• Fracture into piriformis
• Push into varus
• Damage to abductors

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Greater Trochanter Pitfalls

• Varus (ream in varus, plate)
• Short nail in subtrochs (instability and
  fractures propagating from distal screw hole or
  distal nail)
• Ream out lateral wall of trochanter (working
  portal)

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Weakness and Function

• Stannard OTA 2005
• Archdeacon OTA 2006
• Piriformis greater weakness than greater
  trochanter

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Greater Trochanter

• Easier not necessary better (no worse)
• ? flouro time, ? function (PT test)
• Weekness (33 clinical, 33subclinical Biyain
  1993)
• Hip pain (40 Bain 2006)

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Complications of Femoral Nailing

• Most are related to errors in technique or
  judgment

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Reduction Tools

• F tool levering of the shaft
• Femoral Distractor Freehand technique to get
  length
• Spoon or Finger ream proximally and use to
  get guide wire across fracture

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Muscle forces
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IM Reduction

• Prevent varus and apex anteriorly
• Schanz pin laterally in head controls
  varus/valgus
• Ball spike anteriorly for flexion of proximal
  femur
• Must hold reduction throughout reaming and
  fixation

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G.R.75 y.o. male with L subtroch femur fracture
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G.R.
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G.R.
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G.R.
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G.R.
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G.R.
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LAT
AP
Correction of Posterior Sag
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Somethings Amiss Here
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Problem

• Reamed in a poorly reduced position
• Difficult to revise with a nail better fixation
  with a plate

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Revised to A Blade Plate
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HW
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Reduction Tools cont.

• Schanz pins as joystick (blocking pins)
• Tibial traction pin (greater than 24hrs to OR)
• Ball Spike pusher for maintenance of reduction
  during reaming

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CS
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Medical Comorbidities
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DEBATE ?

• Winquest 1984 99 union
• Moed and Ostrum 85-95 union
• Dynamization?
• Ream vs nonream

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Surgeon Summary

• 25 of surgeons use it for shaft fractures
• Easy access in polytrauma and obese patients
  (starting hole)
• Easier to reduce
• No fracture table

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ISSUES

• Patellofemoral joint
• Decrease blood flow to ACL PCL (52, 49)
  canine study (El Maraghy 1998)
• Reamings?
• Indications, Results, Complications

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Indications

• Obesity (less with greater trochanter starting
  point)
• Combination femoral neck femoral shaft
• Multiple trauma (numerous long bones, life
  threatening)
• Segmental bone loss (ilizarov)

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Operative Treatment (cont.)

• Anatomic reduction and fixation at joint 6.5
  screws, 4.0 cannulated screws
• Restore limb alignment (femoral distractor)
• Stable internal fixation

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IM Nail

• Medial parapatellar incision (inferior pole to
  tibial tubercle)
• Starting hole anterior PCL (ream opening with
  conical guide)
• Lined up on the AP and Lateral

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Retrograde Femoral NailingStarting Point
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Indirect Reduction Aids

• Distraction - Pull
• Resident
• Fracture table
• Femoral distractor
• External fixator

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IM Nail (cont.)

• Knee bent 30-40º over a sterile bump
• TDWB 8-12 weeks

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Retrograde Nail

• Within 5 cm of lesser trochanter
• Reamed vs. unreamed

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JS-8-7-03
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Summary of Patients

• 8 patients with 9 patella bajas
• Age 18-75 yo
• Retrograde nail with a secondary procedure on the
  knee ( exchange nail for nonunion )

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Summary cont.

• Surgery - 2 patients anterior release and one
  patient with patellectomy
• 7 patients with significant knee pain, 1
  (patellectomy) minimal pain
• No good treatment for patella baja

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Summary cont.

• Retrograde nail initially not a problem
• Avoid a second surgery after a retrograde nail
• Nonunion with a retrograde nail treat with a
  plate around nail

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AT 7/23/02
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CM-11-30-00
Instant nonunion
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CM-11-7-02
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Titanium Cage Reconstruction
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Technique Titanium Cage
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Technique Titanium Cage

• Cancellous bone packed posteriorly and around
  proximal distal bone-cage junctions

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Lesser Trochanter Sign
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Check Rotation

• Perfect lateral of knee and hip with C-arm 15
  anteversion
• Keep table sterile until check IR and ER at 90
  hip flexion to check symmetry (change distal
  interlocking if more than 10 difference
• Pt with 60 retroversion

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Proximal or Distal Femur Fractures
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NAIL DOES NOT REDUCE FRACTURE
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ORDER OF FIXATION

• Most important - femoral neck
• Most necessary shaft
• Most expertise - acetabulum

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Timing

• Within 24-48 hours injuries most mobile
• 2-5 days may be worst time to operate
• Soft tissue good (includes lung)
• Positive fluid balance

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Good Technique

• Starting hole and direction
• Maintain reduction throughout reaming and
  insertion of nail
• Check rotation and alignment prior to
  interlocking

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UT Orthopaedics
Thank you
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