Algorithm 4 for management of Fracture and Dislcocation around Hip Joint

Old Unreduced Dislocations and Fracture Dislocations

Examination

FADIR

Shortening

Wasting

ASIS often high due to adduction deformity

Round hard , globular swelling palpable in gluteal region

Crepitus

Movement – present only in sagittal plane

Inverted Bryan’ts Triangle

Sciatic Nerve injury (Foot drop )

D/D

            Pathological Hip Dislocation (TB Hip ,Septic Arthrits )

            TB with Destruction of head (painful global restriction of motion in active stage or fibrosis or             ankylosis or hypermobile unstable hip in healed disease )

            AVN hip with destruction of head will have secondary OA and often have external rotation

            Old Unreduced Fracture Neck Femur

           

Investigation

            Xray –

            - Loss of congruity of femoral head and Acetabulum

-          Broken shenton Minard line

-          Proximal migration of greater trochanter

-          Smaller Obturator foramen

-          Samallr Ilium

-          Less prominent trochanter

-          Adducted Femur

CT – To assess associated fracture of Acetabulum ,

MRI –to look for vascularity of head and condition of acetabular soft tissues

Management

            Depends on Thompson and Epstein Classification and Vacularity of Head and Patients condition

Thompson and Epestein for posterior dislocation

Type I

Posterior Dislocation +/- Acetabular fracture

Type II

Posterior Dislocation +/- Posterior wall fracture

Type III

Posterior Dislocation + communited rim fracture acetabulum

Type IV

Posterior dislocation + Rim and floor fracture

 Type V

Posterior Dislocation + Head of femur fracture

Management

Type I

<  3 months – CR under GA , Gupta’s traction

>3 months – Gupta’s method

                Open reduction via anterior or anterolateral approach

Type II

 < 3 months – Open Reduction + Acetabular Reconstruction , Preliminary traction

>3 months – Arthroplasty versus Arthrodesis

(Acetabular cartilage damaged during soft tissue curettage )

Type III

Like Type II

Type IV and V

Younger Patients

            Open Reduction and Reconstruction

Older Patients

            Arthroplasty

NonViable Head (Any type and Duration ) – Arhtroplasty vs. Arthrodesis

Gupta’s Method

CR < 3 months , hip dislocation using traction and Abduction , Upper Tibia – 18 kgs.

When Head at or below acetabular margin , gradually abduct the limb and reduce wight at 3- 6 kgs every 4^th day.

Once reduction achieved , maintain traction at 7 kgs for 2 weeks.

NWB for 4 weeks followed by gradual weight bearing to full weight bearing after 3 months,

Aim – Concetric reduction

At 3 months soft tissue develop inside acetabulum that prevents CR successful.

Malunited / Old Negelected Intertrochanteric Fracutre

Externally roatated , adduction in long stand cases (> 3 months )

Shortening (Supratrochanteric )

Prominent at greater trochanter region

Broadening and irregularity over Greater Trochanter

Decreased abduction , ER and Extension

Movement painful in all direction due to soft tissue impingement

Trendenlenburg test +

SLRT – active +ve , malunited doesnot hamper

Telescopic test –ve

Shortening at base of Bryant’s triangle , increased hypotenuse and perpendicular

D/D

Malunited basicervical neck of femur fracture

Malunited subtrochanteric fracture

Congenital Coxa vara

Neoplasia – GCT at greater trochanter

Sequelae of septic arthritis of hip

Neglected Dysplastic Dislocation of hip

Next Step

X-ray Hip – Involved Side – AP , Lat

 To look for configuration and status of hip

r/o primary pathology , neoplasia , osteoporosis

Long term Problems to patient

Shortening

Trendelenburg lurch

Reduced movements

Hip arthritis

Pain – Recent arthritis

Management

If hip movements are normal , muscle power regained

Options – Conservative

Surgery

Surgery

Corrective valgus osteotomy

Limb length improves

Abductor lurch improves

Pain on hip improves from abnormal transfer of forces across hip .

Complication

Infection

Non union

Patients need to be bed ridden for a week and slowly regain movement over a month to full wight bearing walk and complications of surgery.

Old Neglected Fracutres

( >3 weeks old ) , mobile on fluoroscopy

If < 6 weeks , Open reduction and Bone grafting

            Fixation with sliding hip screw

            Start patient on graduated hip mobilization , muscle strengthening exercises

If > 6 weeks old , not mobile on fluoroscopy

            Wait for fracture union , graduated muscle strengthening progress , osterotomy after 1 year for             fracture to consolidate

Management of IT Fracture

Assess patient medical condition

Most conservative way of management of IT fracture – surgery

Stable fracture – DHS

Unstable fracture -  Intramedullary Fixation

Classification of IT Fracture

Evan’s Classification

            Type I – Undisplaced 2 part intertrochanteric fracture

            Type II – Displaced 2 Fragment fracture

            Type III- 3 fragment fracture without posterolateral support (displaced GT fragment )

            Type IV – 3 Fragement fracture without medial support

            Type V – 4 Fragment fracture without posterolateral and medial support combination of Type III     and IV

R : Reverse Oblique

Unstable IT Frature

Reverse oblique

Lateral wall communition

Medial (posteromedial communition)

Transtrochanteric fracture

Subtrochanteric extension

Options for Stable IT fracture

Sliding hip screws (AO , DHS)

Varible Angle sliding hip screw

Talon compression hip screw

Medoff plate

Percutaneous Comrpession plate

Entry point for lag screw in DHS

2 cm below vastus lateralis ridge

Ideal position of the screw

Centre – centre position of head

Previous posteroinferior location recommendation no longer hold true

            Increased TAD , ECCENTRIC location leads to more rotational stress at fracture site and failure.

Ideal angle of barrel

Available : 135 degrees to 155  degrees

Unstable fracture – posteromedial defect

Force joint reaction transmitted at 160 degrees.

With a larger angle , head will be in valgus to put lag screw at centre – centre postion.This valgus angle leads to meadial gap and construct unstable. Also difficult to negotiate guidewire off the medial cortex to cntre in the head.

For such unstable construct some form of osteotomy is required to improve loading. Otherwise load to failure is higher for stable fracture as the bending forces are minimal and fracture is perpendicular to forces due to valgus reduction.

Practically at 135 degrees barrel plate , posteromedial opening is less and one comfortable places screw at centre of head reducing potential of iatrogenically  displacing the anatomical fracture reduction. Although bending moment is higher than larger angle barrel plate but its preferred for anatomical reduction.

Tip Apex Distance – First referred by Baumgartner , Sum total of distance in millimeter of screw tip of apex of medial femoral head in AP and lateral radiographically after magnification correction. Ideally – 11-25 mm but surgeons tend to TAD < 20 mm .

Why do you call this a lag screw ?

Screw sliding in a barrel plate has no fixed other end.

By itself  doesnot produce compression but facilitates compression . Compression is aided by separate compression screw at rear end of lag screw.

When not to give compression ?

Osteoporotic fractures and weak bones , Chances of screw pull out from concellous bone  so avoid it.

Use of Short barrel plate

Contains 4 holes

Barrel Length – chosen to facilitate optional sliding and collapse without letting screw jam inside barrel  plate under bending moment (Vertical Force )

Larger screw outside barrel plate  ,higher bending moment at screw barrel junction jamming screw.

            Smaller screw – screw touches barrel before complete consolidation occurred.

Short barrel plate for screw lengths less or equal to 80 mm and

Standard bareel length for 38 mm preferred.

            Option for IM Fixation of IT Fracture

-          Gamma nail (2^nd , 3^rd Generation)

-          PFN (Short and long )

-          Intermedullary Hip Screw

-          Trochanteric Hip screw

-          Trochanteric Antegrade Nail

Can all IT fractures be managed with IM Fixation and suited only for unstable IT fracture ?

            Suited only for unstable IT fracture.

            Fracture with large posterior fragment or 4 part fracture .

Fractures where GT not localized or reduced well are not suited for IM fixation due to entry point problems.

Better fixed with TBW of greater tochanter fragment and trochanteric stabilizing plate with a sliding screw fixation.

Alternatives – DCS , Condylar blade plate , (provide a prosthetic lateral wall of metal but unclear how well a support provided )

Thread length of DHS Lag screw

            Standard DHS Lag screw – 22 mm

            Thread diameter – 12.5 mm

            Shaft diameter – 8 mm

            Sizes available

                        50 – 145mm

Why not DHS for reverse oblique fractures (Slanting upward medially ) ?

Unable to resist medial displacement tendency of distal shaft fragment

Proximal fragment pulled by abducotrs and distally by adductors

Lag screw cant hold proximal fragment , it cant

Distal fragment ……

So failure occurs .

IM fixation best suited . DCS or CBP can be used provided there is no medial communition (Medial continuity and contact imperative else they will fail in varus collapse.

Pros and Cons for using IM implant

 Advantages

Ability to fix majority of fractures

Short surgical time and less blood loss for unstable IT fractures ( no differences comparing to DHS fixation for Stable IT fractures )

Smaller Moment arm to bear tensile forces and lesser calcar strain

            DHS produces 1.5 times calcar strain of a normal femur

IM < 10 % of strain

Better controlled collapse as bending moment at lag screw for nail is lesser than DHS.

Biomechanically nail construct more stiff (so more stable ) than DHS for torsion and bending forces )

Disadvantges

Abductor injury while insertion

Difficult revision by arthroplasty if fails

Anterior thigh pain due to impingement of nail tip

Curvature mismatch of nail and femora produces iatrogenic fracture

Stress concentration at nail tip leading to fracture

Costlier implant

Z-effect and Reverse Z effect

Complications arising from fixation of unstable proximal femoral fracture with PFN having 2 screws.

Z –effect – Lateral migration of caudal screw ,varus collapse and perforation of femoral head by superior screw

Reverse Z effect – Lateral migration of superior screw , varus collapse and femoral head cut out by inferior screw

Cause – Varus fixation of fracture , severe medial communition inapporopriate entry point and poor bony quality

Intraoperative procedures to stabilize with unstable IT fracture

Ostotomies and fixed with fixed angled nail plate design ( smith Peterson nail plate )

e..g. 1 Dimon – Hughston medial displacement osteotomy

        2 Sarmiento Valgus Osteotomy

        3 Wayne – County Lateral displacement Osteotomy

No evidence to support these osteotomies with sliding hip screw.

Mechanisms of failure of DHS

Non –union

Screw doesnot slide in barrel

            Screw penetration into hip joint

            Pulling out of  plate and shaft

                        (screws varus collapse )

            Cut out of lag screw through head

            Bending and break at barrel plate junction

Role of Arthroplasty for treatment of unstable IT fracture

            Higher failure rate of unstable IT fracture

            Difficult revision

            So many surgeons do it as a primary procedure

Cemented , Uncemented Hemi / THR – Better in terms of posteoperative complication

Cone prosthesis (Cementless ) – More popular as there is a higher chance of cementless stems subsiding into a wider femoral canal following osteolysis.

But costly , needs expertise.

For poor bone quality ,

            Pharmacotherapy – for osteoporosis , Ca , Vitamin D and oral/IV Bisphosphonates.

            Avoid using  compression screw intraoperatively.

Management options for poor bone purchase in osteoporosis – use bone cement to improve lag screw in femoral head to improve purchase else implants specific to minimize screw cut out.

            Delta Bolt

            Spiral Blade instead of screw

            Injecting cement into screw tract before putting screw

            Talon Compression screw

Role of Bisphosphonates in fracture Healing

            Give Calcium for 3/4 days prior to Bisphosphonates , Give Bisphosphonates at earliest.

            Doesnot delay callus

            No evidence till delay to delay bisphosphonates therapy

r-PTH –Acute stage – Role . with surgery , improves

            healing of bone

            locally administered improves implant anchorage

Non-Union Neck of Femur Fracture

            History of Trauma , inability to bear weight following trauma

            Tender midinguinal point

            Deasault’s sign +

            Telescopy +

            Trendelenburg test +

            Shortening and External Rotation

How to distinguish from Non –union IT Fracture ?

            Irregularity and broadening over trochanter

            Tenderness at trochanteric region rather than mid inguinal

Why not anterior dislocation ?

            Anterior dislocation has extension deformity , lengthening in low types of dislocation.

            Moreover , head not palpable in classic sites.

Why do you think head not dislocated ?

            B/L Narath’s sign +

D/D

            Old Fracture  rt femur head

            Old ununited IT fracture Rt femur

            Malunited Fracture acetabulum posterior wall/  superior wall both after IR deformity as        subluxation occurs posteriorly

            Old treated TB hip

Causes of Non-union Neck of Femur Fracture

            Morphological –high fracture angles – higher Pauwel types – Angle 60 – 90 degrees

            Displaced fractures- Garden type III and IV

            Fracture communition

            Inadequate reduction and stability of fixation

            Poor bone quality

            Injury to vascularity :Direct and tamponade effect (Deyerle)

            Absent cambium layer

            Chondrogenic factors in synovial fluid that inhibits callus formation

            Lack of haematoma formation

            Washing of haematoma formation

            Washing away and dilution of osteogenic factors

What type we see here ? Atrophic

Duration and its effect

            3 weeks – resorption of fracture ends

            Contractures prevent adequate lengthening and reduction

            Acetabular cartilage damage

Investigations

X-RAY – AP and Lateral

            One more view to see neck

           

MRI /Bone Scan – to see viability of head

Radiological Assessment

            Fracture angulation

            Osteopaenia

            Bone loss

            Osteonecrosis

            Calcar Formation        

            Varus Angulation

Lateral Projection        

            Flexion /extension

            Posterior Communition

            MRI /Bone scan to look for vialibity of femoral head

Osteonecrosis radiological assessment

            Grade 6 –Normal , all trabeculae present

            Grade 5 – Loss of trochanteric and secondary tensile , attenuated secondary compressive

            Grade 4 – Loss of secondary compressive , attenuation of primary tensile

            Grade 3 – Break in  primary tensile

            Grade 2 – loss of primary tensile

            Grade 1 – only primary compressive seen also reduced.

When to call non union of Neck of Femur Fracture ?

            At 3 months

Various Options

            ORIF with cancellous Bone grafting

            ORIF with Fibular Strut grafting

            ORIF with Vascularized bone grafting

            ORIF with Vascularized Fibula

            ORIF with Pedicle Bone grafting

            Neck reconstruction

            Osteotomy

            Arthrodesis

            Arthroplasty

            Girdlestone Resection Arthroplasty

Plan of surgery

            Age of Patient

            Presence of osteonecrosis

            Prior hip Symptoms : OA

            Co-morbidities

            Duration from injury

            Fracture variables

                        Site of fracture

                        Fracture configuration

How to classify non union neck of femur fracture ?

            Fracture surfaces

                        Irregular and Smooth

            Size of Proximal Fragment

                        2.5 cm or less

            Cap between fragments

                        Upto 1 cm

                        >1 cm

                        >2.5 cm

Guidelines

            Osteonecrosis and Non union

                        <50 –pedicle grafting vs arthrdesis vs osteotomy (Mc Murray’s)

                        >50 –arthroplasty

            Non and no osteonecrosis (preserved anatomy)

                        <65 years – osteosynthesis

                                             ORIF with Vascularized grafting

                                              ORIF with Fibular grafting

                                              

                        >65 years – Arthroplasty

Non union with destroyed anatomy (neck resorption, no osteonecrosis)

            <65 – Pauwel’s Type Osteotomy

            >40 – Neck Reconstruction

            >65 – Arthroplasty even after 40

Various muscle based grafting

            Muscle pedicle bone grafting

            Quadratus femoris based (Judet)

            Gluteus Medius based (Hibbs)

            Anterior Trochanteric bone grafting (Modified Hibbs)

            Sartorius based (Li)

            TFL Based (Bakshi)

            Gluteus Maximus based (Onosun)

           

Muscle Pedicle Perosteal (Myoperiosteal)

            Gltueus Maximus based (Frankel)

            Vastus Lateralis(Stuck)

Muscle Pedicle Periosteal

            Quadratus Femoris

Combined

            East Asian       

            Sartorius + Deep Circumflex femoral artery based

            Quadratus Based + Osteoperisoteal anterior grafting ?

           

Neck Reconstruction

            Devise trough at end (triangular like ) and fill this with bone graft

            Cage and autologus bone graft

                       

Advantages of Muscle Pedicle Bone grafting

            No substitute for original joint

            Always save a salvageable joint

            Vascularized graft – take care of osteotomy

            Pedicle grafts – less cumbersome than free grafts.

Principles of grafting technique

Vacularized grafts – increase vascularity of devascularized head

Hypovolaemic head turn into normovolaemic

Spontaneous revascularization after ORIF / CRIF stops at antero-superior region leading to   segmental collapse taken care of

Role of Osteotomy in treating Non union of NOF fracture

1.      Osteotomy alters both the mechanical and biological environment around non union which enhances healing or at least provides relief to patient

2.      Altering mechanics – medial shift of line of wight bearing

3.      Realignment of limb during movement

4.      Relaxation of joint capsule      

5.      Increased vascularity

6.      Psoas Relaxation providing pain relief by a mechanism similar to hanging hip of Voss ?

7.      Improved leverage and stability          

8.      Relief of Pressure by muscles

9.      Redistribution of tensile forces at fracture line to compressive forces leading to arm chair effect

             

           

           

           

Whatws arm chair effect ?

Mc Murray’s osteotomy ?

Distal fragement placed directly under its head so weight bearing transmitted directly from head to shaft bypassing neck. So shearing forces converted to compressive forces.

Getting up from a chair without supporting arms – shearing forces concentrate in knee in tensile manner.

Getting up from a chair with arms pushing chair – more or less situated at knee level or even front – dissipating shearing forces in knee.

Recommended for OA of Hip and Knee .

Various Osteotomies for treating hip Non Union

2 Land marks Osteotomies

1)Lineal Ostotomy – Medial dislplacement Ostotomy described by Hans revised by McMurray and Leadbetter .

2)Angulation Ostotomy  -Schanz Osteotomy with modification by Pauwel’s

Mc Murray’s

Medial displacement oblique intertrochanteric osteotomy with PSO .

Principles of Mc Murray’s Osteotomy

1 Upper end of shaft must be just below the edge of acetabulum

2 There must be union between portion of divided femur

Conditions he descrived

OA hip joint , pain , stiffness and deformity

There should be 70 degree flexion at hip.

Pre-requisites

No coxa magna , loss of sphericity of head in both AP and Lateral , dysplastic acetabulum ,subluxation ,inflammatory diseases and ankylsoing spondylitis

How to do it and how to fix it ?

Line of Osteotomy – base of greater trochanter obliquely up (10-15 degrees) to lesser trochanter

Medial displacement of distal fragment

Fixation with WainWright – Hammond Spline plate

By doing adduction , it tilts proximal fragment into valgus making fracture line horizontal .

Mc Murray’s Osteotomy Disadvatnages

Shortening ,Lurching , Frequent Non union at ostotomy site , Difficult future THR

(so not to displace > 50 % ) , genu valgum of  ipsilateral knee

Pauwel’s Osteotomy

Replaces Pseudoarthrosis site to remove shear forces

Osteotomy to enhance fracture healing and other benefits

            . Equlizes limb length

            Lateralization

            Early mobilization by fixing osteotomy

Planning : Body forces subtend an anle of 16 degrees at hip joint.Anatomical axis – 8-10 degrees to body forces so pseudoarthrosis site is subjected to forces at aroind 25 degrees . Substract this from pseudoarthrosis (Pauwel’s angle)

This gives wedge angle to be resected at osteotomy site.Same principle applies for Mc Murray’s osteotomy described for Pseuoarthrosis  of femur Neck.

Which test describes instability at hip joint ?

Telescopy test – Significant telescopy ( > 1 cm trochanter excursion in one direction ) is a good indicator of unstable hip joint , whilest absence of same doesnot substantiate stability.

Telescopy due to absorbed neck , communition at fracture site , tearing of capsule in high impact unjuries.

Tests you can see?

Due to  limitations of telescopic test ,active SLRT  (Stinchfield test ) can be performed.

SLRT – fallacious (false negative ) in impacted fragments ,capsule contracture ,leverage of distal fragment on acetabulum margin.

Absent (false positive)  in a frail patient and cant be done in hemiplegic or paraplegic patient.

Various closed reduction manouevres for fracture in NOF ?

Manouevres in Extension

            Whitman

            Deyerle

            Swinotkowsi

Manouevres in Flexion

Leadbetter : Flexion , IR , Circumduction to abduction and extension ; check by resting heel on palm. It it rest without ER then it’s a secure reduction

Flynn

Smith Peterson Method (gentle Lead Better method )

Assessment of Alignment

Garden’s Index

            AP – 160 , Lateral 180 degrees , Radiographs required

            155 -180 degrees acceptable

Lowell’s S-curves : Image intensification

Mc Elvenny : Hat on hook position

Lindequist and Tronkvist

            Criteria of good reduction < /= 2 mm displacement , AP Garden angulation of 160 – 175 degrees     and lateral angulation of </= 10 degrees.

Shape of Fracture in Neck of Femur fracture

Spiral

Classification

Gardens’s

Complete / Incomplete

Degrees of Displacement

Garden’s Index : based on trabecular disposition in AP (160 ) and Lateral (180) projection

1 Incomplete ,valgus impacted fracture with trabecular displacement (increase Garden’s index in AP , Normal in lateral )

2 Complete ,undisplaced , +/- impaction

3 Complete , displaced (partial displacement < 50 degrees

4 complete ,displaced > 50 percent and dissociation between proximal and distal fragments so that proximal one realigns ) with acetabular trabeculae

Eliassen – Undisplaced (Type 1 , 2 )

-          Displace (Type 3 and 4 )

Linton’s Classification

1 fracture in adduction (varus displacement /angulation : Garden’s Index decrease )

2 fracture in abduction (valgus displacement /valgus angulation )

3 Intermediate type

Pauwel’s Classification

            Angle of Fracture line < 30 degrees

            Angle of Fracture  line 30-50 degrees

            Angle of Fracture line > 50 and </=  70 degrees

Anatomical : subcapital , transcervical ,basicervical

AO

Current classification (Caviglia , Osorio ,Commando )

5 types

             Completeness , contact , angulation and communition

Stress NOF fracture (Fulkerson and Snowdy )

            1 Tension stress fracture – superolateral aspect of neck , increase risk of displacement

            2 compression stress fracture – inferomedial , risk of displacement decrease

            3 completely displpaced NOF Fracture , displaced

Classification in children (Delbet and Colona )

            1 Transphyseal : involves physis +/- dislocation of femur head ,ABER

            2 Transcervical fracture (most common ) – displaced ,unstable ,

                        Osteonecorosis proportional to displacement

            3 Cervicotrochanteric ,2^nd most common

            4 Interotrochanteric – good fracture

Blood supply of femoral head

             Crock description – 3 sources

             A Metaphysis

            B Retinacular

            C Foveal

Extracapsular Arterial Ring of Chung – at base of femoral neck posteriorly – MCFA ,

                        Anteriorly –LFCA ,branch of Profunda Femoris Artery

Ascending Cervical Branches of ECA (aka Epiphyseal artery of Trueta or retinacular arteries ) from ECA.

Divided into anterior posterior medial and lateral groups

Lateral group most important .

Subsynovial intra-articular arterial ring of chung

            (Circulus articuli vascularis of Hunter ) formed from lateral ascending cervical vesssels ,located at margins of articular cartilage on surface of neck of femur

Artery of ligamentum Teres

Branch of obturator (more often ) or medial circumflex femoral artery .

Metaphyseal femoral neck – supplied by a cruciate shaped anastomosis between

            Bracnhes from ascending cervical bracnhes

            Branches from subsynovial intraarticular arterial ring

            Branches of superior nutrient artery system

Metaphyseal vessels from Intertrochanteric region

How to look for Protusio Acetabuli ?

Distance between medial wall of acetabulum and pelvic brim

Gr  I  1-5 mm (Mild )

Gr II  6-15 mm (Moderate )

Gr III > 15 mm (Severe )

Causes

1 Familial /Idiopathic (Otto Pelvis )

2 Rheumatoid Arthritis and JCA

3 Osteoporosis

4 Ostomalacia and Rickets

5 Marfans’s Syndrome ( 45 % have protusio in 50 % )

6 Paget’s

7 Ankylosing Spondylitis

8 OA

9 Acetabular Fractures

10 Osteogenesis Imperfecta