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AO Foundation Education Femoral neck fractures Piet de Boer, York, UK. Ian Harris, Adelaide, Australia

AO Foundation

Education

Femoral neck fractures

AO Foundation Education Femoral neck fractures Piet de Boer, York, UK. Ian Harris, Adelaide, Australia Mariusz

Piet de Boer, York, UK. Ian Harris, Adelaide, Australia Mariusz Bonczar, Crocow , Poland

Objectives

outline the biological and mechanical problems in treating femoral neck fractures

identify the indication for fixation and arthroplasty

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problems in treating femoral neck fractures • identify the indication for fixation and arthroplasty 2

Anatomy, classification

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Anatomy, classification 3 31B

31B

Anatomy, classification 3 31B

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4 m e d i a l circumflex artery lateral circumflex artery Blood supply

medial

circumflex artery

4 m e d i a l circumflex artery lateral circumflex artery Blood supply
4 m e d i a l circumflex artery lateral circumflex artery Blood supply

lateral circumflex artery

4 m e d i a l circumflex artery lateral circumflex artery Blood supply

Blood supply

Anterior

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Anterior 5

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posterior medial circumflex artery
posterior
medial circumflex artery

Blood supply

Cranial anastomosis

biological effect
biological effect

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The posterior retinuacular vessels from the medial circumflex artery provides the main nutrition of the femoral head

7 The posterior retinuacular vessels from the medial circumflex artery provides the main nutrition of the

Proximal femoral fractures

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neck fracture – intracapsular, extraarticular 31-B trochanteric area- head fracture- intracapsular,
neck fracture –
intracapsular,
extraarticular
31-B
trochanteric
area-
head fracture-
intracapsular,
intraarticular
extracapsular
31-C
31-A
31-B trochanteric area- head fracture- intracapsular, intraarticular extracapsular 31-C 31-A Classification

Classification

31-B trochanteric area- head fracture- intracapsular, intraarticular extracapsular 31-C 31-A Classification

AO Classification

B1
B1

subcapital with slight displacement valgus position mostly impacted breakdown of trabecular line

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position mostly impacted breakdown of trabecular line 9 elderly patients low energy osteoporosis female

elderly patients low energy osteoporosis female

position mostly impacted breakdown of trabecular line 9 elderly patients low energy osteoporosis female

AO Classification

B2
B2

transcervical different fracture line angle and position displacement

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B2 transcervical different fracture line angle and position displacement 10 younger patients high energy male

younger patients high energy male

B2 transcervical different fracture line angle and position displacement 10 younger patients high energy male

AO Classification

B3
B3

subcapital displaced no impaction different degree of displacement

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AO Classification B3 subcapital displaced no impaction different degree of displacement 11

Garden Classification (1961)

Garden Classification (1961) I II III IV appearance of the trabeculae of the femoral head on

I

Garden Classification (1961) I II III IV appearance of the trabeculae of the femoral head on

II

Garden Classification (1961) I II III IV appearance of the trabeculae of the femoral head on

III

IV

appearance of the trabeculae of the femoral head on AP X-ray

high degree of interobserver variation

difficult to predict complication ( esp. grade III and IV )

only division on undisplaced ( I, II) and displaced (III, IV)

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to predict compli cation ( esp. grade III and IV ) • only division on undisplaced

Pauwels classification (1935)

Pauwels classification (1935) < 30° 30° - 70° > 70° shearing forces at the site of

< 30°

30° - 70°

> 70°

shearing forces at the site of fracture

high degree of inter and intraobserver variation

preoperative angle has no correlation with the subsequent

incidence of complications (except undisplaced fractures)

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angle has no correlation with the subsequent • incidence of complications (except undisplaced fractures) 13

Classification? what does determine outcome?

displacementundisplaced vs displaced stabilitystable vs unstable

valgus impacted are stable

outcome? displacement ― undisplaced vs displaced stability ― stable vs unstable valgus impacted are stable 14

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outcome? displacement ― undisplaced vs displaced stability ― stable vs unstable valgus impacted are stable 14
outcome? displacement ― undisplaced vs displaced stability ― stable vs unstable valgus impacted are stable 14
outcome? displacement ― undisplaced vs displaced stability ― stable vs unstable valgus impacted are stable 14

Incidence

Elderly

Majority

Low energy

Osteoporosis

Female

Young

High energy

Male

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Incidence Elderly • Majority • Low energy • Osteoporosis • Female Young • High energy •

Diagnosis

AP and lateral x-ray

Hip pain in elderly patient post-fall with normal x-ray

- Bone scan

- “Limited” MRI (magnetic resonance imaging)

- CT (computed tomography) scan

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with normal x-ray - Bone scan - “Limited” MRI (magnetic resonance imaging) - CT (computed tomography)

Classification

Displaced (stable) vs undisplaced (unstable)

Valgus impacted are stable

Classification • Displaced (stable) vs undisplaced (unstable) • Valgus impacted are stable 17

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Classification • Displaced (stable) vs undisplaced (unstable) • Valgus impacted are stable 17

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impacted

valgus

stable

do not reduce !

18 impacted valgus stable do not reduce !

Prognosis

Depends on displacement

Avascular necrosis

Nonunion

Osteoarthritis

Deformity (shortening, varus)

Depends on displacement • Avascular necrosis • Nonunion • Osteoarthritis • Deformity (shortening, varus) 19

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Depends on displacement • Avascular necrosis • Nonunion • Osteoarthritis • Deformity (shortening, varus) 19
Depends on displacement • Avascular necrosis • Nonunion • Osteoarthritis • Deformity (shortening, varus) 19

Undisplaced fractures

Internal fixation will result in only 10% failure rate

Safe and simple to fix

- Percutaneous or mini-open

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• Internal fixation will result in only 10% failure rate • Safe and simple to fix

Indication for fixation

Impacted and undisplaced fracture: cannulated screws—implant of choice

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minimal exposure parallel to allow compression
minimal exposure
parallel to allow
compression

Displaced fractures

Elderly patients (the majority)

- High rate of failure for internal fixation

- Joint arthroplasty gives most reliable results

Early weight bearing

Lower failure rate

Young patients

- Internal fixation is more reliable than in elderly

- Arthroplasty is less reliable

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failure rate • Young patients - Internal fixation is more reliable than in elderly - Arthroplasty

Treatment algorithm

Treatment algorithm under 55 23 displaced 55-8 5 no significant co-morbidity over 85
Treatment algorithm under 55 23 displaced 55-8 5 no significant co-morbidity over 85

under 55

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displaced

Treatment algorithm under 55 23 displaced 55-8 5 no significant co-morbidity over 85

55-85

no significant co-morbidity

Treatment algorithm under 55 23 displaced 55-8 5 no significant co-morbidity over 85

over 85

Treatment algorithm under 55 23 displaced 55-8 5 no significant co-morbidity over 85

Internal fixation

Reduction

Traction table

Open reduction if required

Internal fixation Reduction • Traction table • Open reduction if required 24

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Internal fixation Reduction • Traction table • Open reduction if required 24

Internal fixation

Multiple cannulated screws

Dynamic hip screw

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Internal fixation • Multiple cannulated screws • Dynamic hip screw 25
Internal fixation • Multiple cannulated screws • Dynamic hip screw 25
Internal fixation • Multiple cannulated screws • Dynamic hip screw 25

Internal fixation

Multiple cannulated screws

- Minimal exposure

- Parallel to allow compression

Dynamic hip screw

- Increased stability

- Increased exposure and bone loss

- Allow compression

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compression • Dynamic hip screw - Increased stability - Increased exposure and bone loss - Allow

Internal fixation

Internal fixation 27

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Internal fixation 27

Internal fixation—complications

30% fixation failure/loss of reduction

Avascular necrosis

Nonunion

Internal fixation—complications • 30% fixation failure/loss of reduction • Avascular necrosis • Nonunion 28

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Internal fixation—complications • 30% fixation failure/loss of reduction • Avascular necrosis • Nonunion 28

Arthroplasty

Indications

Primary: Elderly, low demand, osteoporotic

Secondary: Failed fixation, nonunion

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Arthroplasty Indications • Primary: Elderly, low demand, osteoporotic • Secondary: Failed fixation, nonunion 29

Arthroplasty—options

Hemi- vs total joint arthroplasty

Bipolar vs unipolar

Cemented vs uncemented

Approach

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• Hemi- vs total joint arthroplasty • Bipolar vs unipolar • Cemented vs uncemented • Approach

Arthroplasty—options

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Arthroplasty—options 31

Arthroplasty—options

In the elderly, cement is preferred

No significant difference between bipolar and unipolar

Hemi-arthroplasty vs total hip

- Smaller operation

- Lower dislocation rate

- May not last as long as total joint replacement

Anterolateral vs posterior approach

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- Lower dislocation rate - May not last as long as total joint replacement • Anterolateral

Arthroplasty—complications

Dislocation

Infection

Acetabular erosion

Leg length inequality

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Arthroplasty—complications • Dislocation • Infection • Acetabular erosion • Leg length inequality 33

Further reading

Further reading Internal fixation vs arthroplasty: - Cochrane - Orthopaedic trauma directions 34

Internal fixation vs arthroplasty:

- Cochrane

- Orthopaedic trauma directions

Further reading Internal fixation vs arthroplasty: - Cochrane - Orthopaedic trauma directions 34

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Summary

Prognosis is dependent on displacement

Internal fixation is indicated for all undisplaced (stable) fractures, and for all fractures in young patients

Arthroplasty is indicated for displaced fractures in the elderly

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and for all fractures in young patients • Arthroplasty is indicated for displaced fractures in the

Summary

Treatment is mechanically based……

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Summary Treatment is mechanically based…… 36 but results Results are biologically dependent!
Summary Treatment is mechanically based…… 36 but results Results are biologically dependent!

but results

Summary Treatment is mechanically based…… 36 but results Results are biologically dependent!
Summary Treatment is mechanically based…… 36 but results Results are biologically dependent!
Summary Treatment is mechanically based…… 36 but results Results are biologically dependent!
Summary Treatment is mechanically based…… 36 but results Results are biologically dependent!

Results are biologically dependent!

Summary Treatment is mechanically based…… 36 but results Results are biologically dependent!