Displaced ORIF

Indications

 

< 60 with good bone stock and preserved joint space

 

Reduction

 

Union rates increased with anatomical reduction

 

Options

- closed reduction

- open reduction / if closed reduction fails

 

Accept

- no varus

- < 15o valgus

- < 10o AP plane

 

Assessment of reduction

 

1.  Femoral neck shaft angle

 

2.  Garden alignment index

- angle of compression trabeculae to femoral shaft on AP should be 160o

- angle of compression trabeculae to femoral shaft on lateral should be 180o

 

3.  Lowell's alignment theory

- head neck junction should make a smooth S / reverse S on all views

 

4.  Restoration of Shentons line

 

Closed Reduction

 

Set up

 

Traction table / radiolucent table

 

Leadbetter Maneuver

 

FATI CAR

- flexion / adduction / traction / IR 

- circumduction / abduction

- reduction Check in extension

- "Foot in Palm Test"

- if sufficiently reduced will sit without ER

 

ORIF

 

Cannulated screws / DHS + derotation screw

 

Aminian JOT 2007

- biomechanical study of strength of fixation of vertical fractures

- locking plate > dynamic condylar screw > dynamic hip screw / 3 cannulated screws

 

Capsulotomy

 

Theory

- decrease intracapsular pressure

- in animal models increases blood flow

 

Options

- open capsulotomy via Smith Peterson

- percutaneous needle drainage of hematoma

 

Open Reduction

 

Vumedi surgical technique

 

Set up

 

Radiolucent table

- floppy lateral with sandbag under affected hip

 

Technique Watson Jones approach

 

Lateral incision

- curvilinear between anterior aspect greater trochanter and ASIS

 

Flexing hip 20-30o helps exposure

 

Superficial dissection

- identify interval between gluteus medius and tensor fascia lata (TFL)

- divide fascia lata

- identify fat pad inferiorly, muscle gluteus medius superiorly

- develop this interval to anterior femoral neck

- lateral femoral circumflex artery in this interval

- place retractors over inferior femoral neck and superior femoral neck

 

Deep dissection

- remove fat pad

- release reflected head of rectus femoris off anterior capsule

 

L or T Capsulotomy

- superior border femoral neck and intertrochanteric line

- tag and reflect capsule

- place retractors inside the capsulotomy to expose the femoral neck

- avoid dissecting superior aspect of femoral neck where major artery of MCFA runs

- can place superior retractor on ilium

 

Steinman pin in femoral head

- allows manipulation and reduction

 

Second steinman pin in femur

- correct external rotation force

 

- obtain anatomical reduction under direct vision

 

Can place the implant through the same incision

- split ITB and vastus lateralis

- fixation of reduction

 

Check reduction on image intensifier

- ensure no varus on AP

- obtain lateral by adducting and IR hip / ensure good reduction on lateral

 

Ensure 2 guide wires centrally in femoral head

- 2 hole DHS + derotation screw (strongest)

- 3 or 4 cannulated screws

 

Open subcapital ORIF

 

Technique Smith Petersen

 

Advantage

- may be better in larger patients

 

Disadvantage

- separate incision for implants

 

Incision

 

3 - 4 cm lateral to ASIS

 

Superficial approach

- between TFL and sartorius

- divide fasica over TFL

- reflect muscle of TFL laterally

- identify and control branches of lateral circumflex artery

 

Capsulotomy

- superior femoral neck and intertrochanteric line

 

Smith Petersen Approach 1Smith Petersen Approach 2Smith Petersen Approach ORIF

 

Options

 

Unstable fracture

- augment with a plate on inferior neck

 

Displaced Subcapital Inferior PlateDisplaced ORIF Lateral

 

Results

 

Age

 

Rogmark et al JBJS Am 2002

- multicenter RCT patients > 70 years with displaced fracture

- ORIF 43% failure

- hemiarthroplasty 6% failure

 

Timing

 

Jain et al JBJS Am 2002

- retrospective review of displaced fractures in 29 patients < 60

- significant reduction in AVN if fixed within 12 hours

 

Complications

 

AVN

 

Subcapital NOF AVN

 

Incidence

 

Undisplaced <10%

Displaced  20-33% 

 

Risk factors

 

Displacement

Injury velocity

Delay in Reduction

Non-anatomical Reduction

 

Pathology

 

Whole head or small wedge 

- most common anterosuperiorlateral

 

Revascularization  

- existing med and lateral epiphyseal blood vessels

- metaphyseal BV crossing fracture

- reduced by mal-reduction / non union

 

Only 30% with AVN will need re operation

 

Management Options

 

Older patient

- arthroplasty

 

Younger patient

- forage / vascularized fibula graft / non vascularised bone graft

- osteotomy

 

Non-Union

 

Incidence 

 

9-33%

 

Risk Factors

 

Intial displacement

Non anatomical reduction

Instability

No compression across fracture

Vascularity - can unite if avascular

 

Failed Subcapital ORIFSubcapital ORIF Lateral

 

Subcapital Nonunion 1Subcapital Nonunion 2

 

Management

 

Older patient

- arthroplasty

 

Young patient

- valgus osteotomy

 

Subcapital NOF Non UnionSubcapital NOF Nonunion CTTHR post Subcapital Nonunion

 

Valgus osteotomy

 

Indications

- patient must have at least 15o adduction

 

Template

- aim to reduce the angle of the neck fracture to between 20 - 30o from horizontal

- this places it perpendicular to the forces acting across the hip

- measure angle of fracture from horizontal (usually 40 - 50o up to 70o)

- difference is angle of correction (20 - 30o)

 

Technique

- insert guide wire in centre of head / for screw

- place K wire superiorly in same plane as this wire at level of LT

- second K wire below at angle of required osteotomy

- resect bone piece

- apply appropriately angle device

- ensure straight line down femur in AP and lateral if need subsequent THR