Controversial Case Discussion: fractures around the hip

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Controversial Case Discussionfractures around
the hip

• Ph Adam
• Arthroplasties in fractures around the hip

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Case 1 femoral neck fracture
86 years old lady Parker score 4 Fall from her
height Clinostatism MMS 22/30 Past medical
history left bipolar hemiarthroplasty of the hip
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Garden I Garden II
Garden classification relies on AP view
Garden III Garden IV
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Treatment options in the elderly

• Functional
• Union 86 of survivors (Raaymakers and Marti, J
  Bone Joint Surg Br 1991), decrease with age
• Displacement 31 (Simon et al., Rev Chir Orthop
  2008)

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Femoral neck fixation under fluoroscopic guidance
on traction table with percutanous parallel
screws respecting valgus impaction
Full weight bearing allowed
Postoperative control
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Evolution at 3 months Marked displacement and
intra articular protrusion
Was this predictable?
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Complications

• Bloomfeld et al (JBJS 2005). Comparison of
  internal fixation with total hip replacement for
  displaced femoral neck fractures. Randomized,
  controlled trial performed at four years.

When looking at lateral view displaced femoral
fracture
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Treatment of displaced intracapsular femoral neck
fracture

• By the age of 85, life expectancy for a woman is
  6,5 years according to demographic datas in
  France
• Indication of bipolar hip arthroplasty retained
  and carried out
• Posterolateral approach
• Full weight bearing allowed

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• 2 weeks after hemiarthroplasty
• Felt in comunity hospital durig rehabilitation
• Reduction in emergency under general anesthesia
  without curarisation

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• Acute, post reduction, intraprosthetic
  dislocation
• Loubignac and Boissier, Rev Chir Orthop 1997,
  Cup dissociation after reduction of a
  dislocated hip hemiarthroplasty
•  can opener  effect
• Favoured by forceful manipulation
• Needs open reduction

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• Open reduction using same posterior approach
• Marked instability due to defect in
  posterosuperior brim

Totalisation with cementless dual mobility socket
Sah and Estok, J Bone Joint Surg Am 2008 22
instability after conversion of bipolar
hemiarthroplasty to total hip arthroplasty
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Take home message

• Beware  undisplaced  femoral neck fractures
• Less than perfect fixation is just not enough

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Case 2

• A puzzling subtrochanteric fracture

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Case 2

• 69 years old lady
• Hip arthrodesis 40 years before to treat
  osteoarthritis
• No hardware removal Smith Peterson nail with
  AntLat approach
• No walking support
• Mild back pain

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Controversial case discussion

• 69 years old lady
• Fall from her height
• subtrochanteric fracture starting from
  introduction point (stress raiser)
• On examination gluteus medius contraction, no
  deformation of knee joint
• Treated for osteoporosis

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Controversial case discussion

• Rare condition Treatment options
• Orthopaedic treatment
• Osteosynthesis with plates
• Osteosynthesis with nail
• Conversion to THR
• Conversion to THR osteosynthesis

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Conservative treatment Expected difficulties
case 2

• Orthopaedic treatment
• Only mentionned because least displaced
• No report in the litterature would increase risk
  of non union, and risk of stiff knee
• Would leave stress raiser in situ
• Stoltz and Ganz, CORR 1976 Fracture after
  arthrodesis of the hip and knee

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Conservative treatment Expected difficulties
Case 2

• Achieve consolidation
• Long lever arm with fusion of proximal joint
• Double plating
• Manzotti et al., J Bone Joint Surg Br 2007
• Subtrochanteric location
• Introduction of trochanteric nail
• CCD 160
• Stabilize fracture
• with retrograde nail
• Wulke et al., J Orthop Trauma 2004

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Conversion to hip arthroplasty Expected
difficulties
case 2

• Convince patient
• After long lasting succesfull arthrodesis
• Manzotti et al., J Bone Joint Surg Br 2007
• Walking stick often necessary
• Panagiotopoulos et al. Instr Course Lect 2001
• Avoid nerve injury
• Up to 7 of cases of conversion (scared tissue,
  lengthning
• Joshi et al., J Bone Joint Surg Am 2002
• Achieve hip stability
• Recurrent dislocation present although short
  series
• Wolfel et al., Z Orthop Ihre Grenzgeb 2000,
• Schuh et al., , Orthopade 2005

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Conversion to hip arthroplasty advantages
case 2

• Bone healing promoted with lowering of stress at
  fracture site
• Alwattar and Egol, Joint Dis Rel Surg 2007
• Improvement of back and knee pain
• Wolfel et al., Z Orthop Ihre Grenzgeb 2000
• Panagiotopoulos et al. Instr Course Lect 2001

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case 2
Our treatment option conversion to
THR transgluteal approach use of a cementless
femoral implant with quadrangular section
rotational stability no cement
interposition cementless dual mobility socket
with pegs and screw
Postop Weight bearing below pain threshold with
2 crutches for 6 weeks
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Case 2
Complete bone healing at 3 monthes
Evolution
At 2 years FU no pain (hip or back) one stick
for walking outside mild limp no
dislocation flexion 80 equal length
2 years FU
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Case 3

• A problem on the raise

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Case 3

• 84 years old man
• Fall in the stairs
• Left hip injury
• Previously
• Ethmoidectomy (10y)
• Balance disturbance
• Emphysema

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Case 3
2 columns fracture Superior impaction Osteoporosis

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Treatment options
Case 3

• Conservative
• ORIF
• Minimally invasive IF /- early hip replacement
• Acute THR with reconstruction

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Functional treatment
Case 3

• Not feasible in this case intractable pain
  during nursing
• Seating position impossible

Traction

• Decubitus not well tolerated
• Displaced Posterior column
• Hesp and Goris, Acta Chir Belg 1988 (80
  unsatisfactory results when posterior involvement)

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Displaced acetabular fracture in the elderly
Case 3

• ORIF relatively good results in the elderly even
  with less than anatomical reduction
• Helfet et al., J Bone Joint Surg Am 1992
• Unless
• Posterosuperior impaction
• Marked osteoporosis
•  gull sign 
• Anglen et al., J Orthop Trauma 2003

The gull sign
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Displaced acetabular fracture in the elderly
Case 3

• Percutaneous osteosynthesis
• in non displaced fractures
• Most suitable for anterior column fractures or to
  unite both columns
• Mouhsine et al., Injury 2005
• Mears, J Am Acad Orthop Surg 1999

Mouhsine et al.
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Displaced acetabular fracture in the elderly
Case 3

• Arthroplasty good immediates results unless
• Instability (large exposure, soft tissue trauma,
  elderly)
• Neurologic complication
• Mears and Velyvis, J Bone Joint Surg Am 2002
• Can be associated with osteosynthesis
• Boraiah et al., J Orthop Trauma 2009

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Our option
Case 3

• Acetabular reconstruction using Kerboull
  reinforcment ring and cemented dual mobility cup

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Follow up
Case 3

• Seating at day 2
• Verticalization
• Touch weight bearing 6 weeks

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Follow up
Case 3

• No further migration at 3 months
• No pain on standing position
• No dislocation

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Discussion
Case 3

• Additional osteosynthesis of posterior column
• Secures contruct
• Boraiah et al., J Orthop Trauma 2009
• Use of ilioischiatic rings

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Conclusion

• Instability is an issue when hip arthroplasty is
  to be performed in acute cases in the elderly