Femoral neck fractures

Transkript

1 Femoral neck fractures Golden standard and breaking news Anders Jordy Traumesektoren, Kolding Sygehus AO advanced principles Middelfart, april 2016

2 Learning outcomes Forstå hvilke forhold hos patienten, der kan have indflydelse på behandlingsvalget Kende til vigtigheden af korrekt reposition Kunne vælge mellem de mange forskellige implantater I forhold til frakturmorfologi Kende korrekt fikseringsteknik Kende til overvejelserne omkring osteosyntese vs. alloplastik hos den ældre patient

3 Behandlingsmuligheder værktøjskassen Skruer hip pins Hansson etc. Glideskrue med eller uden antirotationsskrue Hemialloplastik Cementeret Ucementeret Unipolær Bipolær THA Cementeret Ucementeret Dual mobility cups

4 Patienten Incidens /år i DK Flertallet > 80 år, ¾ kvinder Høj biologisk alder Co-morbiditet Faldpatienter -> ligget længe på gulvet -> dyhydrering, delir mm. Udsat for polyfarmaci Afhængig af pårørende/hjemmepleje Mindretallet Uafhængig af hjælp fra andre Raske ift. alder Unge Aktive

5 Fracture pattern

6 Golden standard DOS Referenceprogram for hoftebrud, 2008 Hvidovrealgoritmen

7 Golden standard referenceprogram Osteosyntese Forskudte og uforskudte brud hos patienter under 70 år (A) Uforskudte brud hos ældre > 70 (A) intern fiksation med 2 eller flere parallelle eller med 2 huls glideskrue (A) Artroplastik Forskudte frakturer hos patienter over 70 år (A) år uden demens kan behandles med THA såvel som hemialloplastik (A). > 80 eller demente: hemialloplastik (B).

8 Golden standard referenceprogram Teknik ved intern fiksation den distale skrue hviler på calcar (D) afstanden fra skruespidsen til den subchondrale knogle ikke overstiger 5 mm (D) indsættes 3 eller flere (?) skruer tilstræbes spredning af skruerne i sideplanet (D). væsentligt at undgå penetration af caput med boret (D) undgå rotation af caput i forbindelse med isætning af skruer (D). Teknik ved artroplastik moderne cementeringsteknik (D). Ved hemialloplastik kan såvel unipolært såvel som bipolært caput anvendes (A). At der anvendes modulære komponenter der tillader skift til THA, uden at stemmet skal fjernes (D). At ucementerede proteser af Moore type ikke anvendes (A).

9 Golden standard

10 Reduction is essential hvis man vil bevare caput

11 31-year-old, skiing accident 1. Sehr junge Patienten: Schrauben möglich

12 Breaking news nyere artikler Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. Rogmark, C; Leonardsson, O The Bone & Joint Journal. 98-B(3): , March DOI: / X.98B Review af RCT er og registerstudier Lateral eller posterior approch ved alloplastik Given the seriousness of recurrent dislocations and its early occurrence, the direct lateral approach is preferable Cementeret eller ucementeret hemiallo Cementless stems increase the risk of reoperation due to periprosthetic fracture by 20 times THA vs. hemi og Uni- vs. bipolar hemi no clear-cut evidence-based recommendation can be made

13

14 Teriparatide rekombinant human PTH Two prospective randomized double-blind, placebo-controlled Phase III studies were designed to evaluate the effect of subcutaneous teriparatide (20 μg/day) for 6 months versus placebo on fracture healing at 24 months

15 Teriparatide rekombinant human PTH Primær endpoint: no revision surgery at 12 months 84% in the intervention group vs. 88% in placebo group, p=0.743 Radiographic fracture healing at 12 months (75% placebo versus 73% teriparatide p = 0.692) pain control (such as pain during ambulation, 92% placebo versus 91% teriparatide; p = 0.681). Conclusions The small sample size limited this study s power to detect potential differences, and the results are exploratory. Further large controlled studies are required to determine the effect of teriparatide on fracture healing.

16 Breaking news eller freaking news!? To eller tre skruer? Diskuteret længe -> hvis godt reponeret er 2 skruer tilstrækkeligt. Kan man opnå bedre stabilitet ved at sætte 3 skruer på en anden måde. Cadaver studie

17 Hvad med at placere skruerne på en ny måde, the F-technique

18 Fig. 1. Schematic of the conventional method with three parallel cannulated screws. Only one distal calcar-buttressed screw is used. Its contact point on the calcar is at the level of the medial part of the femoral neck (cross section b). The parallel screw orientation allows placement angles of maximally. The screws are too close to each other.. Unique stability of femoral neck fractures treated with the novel biplane double-supported screw fixation method: A biomechanical cadaver study Injury, Volume 46, Issue 2, 2015,

19 Hvad med at placere skruerne på en ny måde, the F-technique Conclusion By providing better cortical support, from a biomechanical point of view the novel BDSF method increases femoral neck fracture fixation strength, improves osteosynthesis outcomes, and extends the indications for internal fixation when osteoporosis is present. Further clinical studies should be performed to address the question for immediate postoperative full weight bearing without any restriction as recommended in our clinical practice

20 Intervention: Open reduction of the femoral neck, fixed with a lengthand angle-stable construct of 2 fully threaded cannulated screws augmented with an endosteal fibular allograft serving as a biologic dowel. Main Outcome Measurements: viability of the femoral head and the fibular allograft osseous union - evaluated using a specialized sequence of contrastenhanced magnetic resonance imaging (MRI) obtained at 3 and 12 months postoperatively..

21 Watson Jones approach

22 Results: high union rates (89%; 24 of 27). The clinical and radiographic outcomes were excellent. Twelve-month MRIs revealed either partial or complete osseous incorporation of 86% the fibular allografts. Conclusions: The fibular allograft reconstructs the comminuted femoral neck osteointegration overtime increases the strength of the host bone graft interface. This added strength seems to provide the stability needed to better preserve the intraoperative reduction, obtain good outcomes, and reduce the complications associated with FNF.

23 Take-home messages Behandlingsvalget er afhængig af både frakturen og patienten Golden standard idag er baseret på rimelig god evidens Anatomisk reposition er essentiel hvis man ønsker at bevare caput Nyere forskning koncentrere sig om aldersgrænser for osteosyntese og valg mellem forskellig protesetyper og adgange Der er ikke rigtig nogen nye osteosyntesemetoder, der virker overbevisende