Hip Fractures Treatment & Surgery PDF

Hip Fractures High Energy (Young) Hip and Pelvis MVC/Fall from height Non-operative Treatment and Non-Art...

Hip Fractures High Energy (Young) Hip and Pelvis MVC/Fall from height Non-operative Treatment and Non-Arthroplasty Surgery Unstable Fracture Jeffrey J. Nepple, MD, MS Associate Professor Co-Director, Hip Preservation Washington University Orthopaedics Hip Hip Fractures Fractures Anatomic Location Low Energy (Elderly) Femoral neck fracture Ground level fall (90%) Intertrochanteric fracture Impacted fracture (stable) Displaced fracture (unstable) Subtrochanteric fractures 1 Hip Fractures Hip Fractures Anatomic Location Low Energy Risk Factors: Weak bone, unstable gait – Increased Age – Alcohol/Caffeine – Female Gender – Dementia/Delirium – Urban > Rural – Medications – Prior hip fracture Hip Fractures Hip Fractures Mortality Risk, 1 Year (14-36%) Management Principles Risk Factors Fix young, replace old Non-op only for sick – Age – Poor Nutrition patients with stable impacted fractures or unfit for surgery – Male Gender – Dementia Surgery for most – Systemic Disease – Institutional Living (CV, Renal, Pulm) Evaluate/correct medical conditions Mobilize early postop – WBAT in elderly 2 Femoral Neck Fx (Elderly) Femoral Neck Fx (Elderly) Garden Classification Garden Classification Non-Displaced Fractures Displaced Fractures I- Incomplete/Valgus Impacted III- Partially Displaced (Stable) (Unstable) II- Complete, nondisplaced IV- Completely Displaced (Not Stable) (Unstable) Femoral Neck Fx (Elderly) Femoral Neck Fx (elderly) Nondisplaced/stable Displaced/unstable Open reduction, internal fixation Older Patient (> 60 years) – Multiple Screws Hemi vs total hip arthroplasty Complications Cemented vs cementless – Nonunion (5-25%) – Screw cut out/penetration (4-6%) Complications: – AVN (10-40%) – Fracture Disruption of MFCx artery – Dislocation 3 Femoral Neck Fx Intertroch Hip Fx Young patients Intro Younger Patient (< 60yr) Elderly fx pattern with OA ORIF Similar incidence as Surgical urgency femoral neck fx Anatomic reduction is critical – Recent data showing radiographic reduction may be Similar Risk Factors more important Complications: AVN, nonunion M>F Low / No AVN Risk Intertroch Hip Fx Intertrochanteric Femur Fractures Classification – Stable versus unstable Treatment – Stabilize and compress fracture Intramedullary Nail (IMN) – Normal obliquity Dynamic Hip Screw (DHS) – Reverse Obliquity – Postop (young/High energy) WBAT No ROM restrictions Strengthening when healing present 4 Intertroch Hip Fx Subtrochanteric Femur Fx Complications Characteristics Fracture at/below lesser troch Loss of fixation (4-12%) High stress region of the femur Hardware complications – Lateral screw irritation Higher incidence of delayed union and malunion Malunion Young – high energy Old - Association with osteoporosis medications (bisphosphonate induced) Subtroch Femur Fx Subtroch Femur Fx Treatment Treatment IMN Wt Bearing Based on Fx Stability – Often with open reduction No Hip Precautions Fixed angle plate devices – 95 Degree dynamic compression Complications screw – loss of fixation – Blade Plate – nonunion 5 Osteonecrosis Osteonecrosis Etiology Etiology Big Three Vascular insult – Medical Steroids – Bone Edema – ETOH – Decreased inflow – Trauma Healing process impaired Rare Conditions – Bone resorption – Sickle cell dz > trait – Gaucher Disease Articular Collapse – Myeloproliferative disorders – Secondary Arthritis – Transient Osteoporosis (pregnant females / 60 year old men) Staging Staging Ficat-Arlet Ficat-Arlet , III - subchondral collapse 0 - normal MRI IV – collapse with flattening of head I - Pain with normal X-ray, positive MRI V – narrowing of joint II – Mixed lysis and sclerosis VI – advanced OA 6 Osteonecrosis Osteonecrosis Nonsurgical Treatment Operative Treatment Nonoperative Core Decompression – Protected weight bearing – No Graft – Bisphosphonates (Short Term) – Non-Vascularized Graft – Vascularized Graft Historical, Reproducible? Osteonecrosis Osteonecrosis Core Decompression Operative Treatment Osteotomy Have to protect weight bearing to decrease risk of fracture through “stress riser” Traditional Osteotomy rotates the femoral head under the acetabulum Osteotomy for AVN rotates the involved part of the femoral head out from under the acetabulum 7  Osteonecrosis Hip Instability Operative treatment Total Hip Arthroplasty For cases with femoral head collapse THA Instability Hip Dislocation Etiology Primary THA- 1-5% Revision THA- 7-15% Factors – Component Position Acetabular alignment Femoral offset Femoral length Combined rotation Soft tissue tension 8 Hip Dislocation Hip Dislocation THA THA Decreasing Incidence Timing and Treatment – Femoral components that Acute Dislocations match patient anatomy – Most occur within 3 months of THA. Breach of restrictions – Larger femoral heads – Initial Treatment- Reduction and Dual mobility bracing. Most have no further issues – Soft tissue management – Revision- recurrent dislocation with components are malpositioned Hip Dislocation Hip Dislocation THA THA Timing and Treatment Revisions Chronic Dislocations Component Position Acceptable Constrained Acetabular Liner – Generally occurring years after THA Dual mobility – More prone to recurrence – Initial Treatment- Reduction and bracing Component Position Not Acceptable – Revision- If components are malpositioned Component Revision 9  Hip Instability Hip Instability Native Hip Native Hip Posterior Dislocation- 85% Poor Prognosis: High energy trauma- MVC Child – (Knee to dashboard) Unreduced Dislocation Loading on flexed hip > 12 hours – Posterior Dislocation Acetabular Wall Fracture Associated femoral neck – fracture – Femoral Head Fracture Hip Dislocation Stress Fracture Treatment Etiology Prompt Reduction Repetitive Trauma/ Increased activity relative to baseline Assess for associated injury – Knee- PCL injury Military recruits Hip Dislocation Precautions Long Distance runners Rehabilitation within precautions Bisphosphonate Use (chronic) 10 Stress Fracture Stress Fracture Xray Findings Treatment Bone scan- increased activity Protected wt bearing MRI- Linear Edema In situ fixation “Black line” = Fracture Open Reduction Internal Xrays- Fixation (ORIF) – No abnormality – Mild increase in bone density – Linear radiolucency Hip Infections Hip Infection Demographics Population affected – Young children – Immunocompromised adults – Post-surgical pts 11 Hip Infection Hip Infection Clinical Features Dx / Rx Presentation Laboratory Studies ESR, CRP, CBC – Pain – Joint Aspiration Cell Count – Fever Culture – Decreased Range of Surgical urgency Motion – Emergency - if septic – I&D – Wound issues Hip Infection Hip Infection THA/ Hemi THA/ Hemi Resection Arthroplasty < 24-48 hrs of symptoms – I&D Components Removed – Prolonged Abx >6wk Debridement performed – 2 stage revision – Prolonged abx +/- Antibiotic Spacer Last resort: – Resection Arthroplasty (Girdlestone) 12 Heterotopic Ossification HO Etiology Treatment Bone formation in muscle/ Prevention (THA) soft tissue – Indocin – Low Dose Irradiation Trauma or surgery – Fracture Surgical excision – Dislocation – Postop Irradiation – Hip Replacement – Bone forming conditions (DISH) Rehabilitation- AAROM PELVIC FRACTURES Pelvic Fractures Etiology High energy trauma – Associated life threatening injuries – Complex fractures usually requiring CT scan for evaluation Low Energy Injury – Insufficiency Fractures 13 Pelvic Fractures Etiology Pelvic Fractures Etiology Frequently result from high energy trauma Low energy fall in elderly patient Life threatening injuries may also occur Rare insufficiency fracture Complex Fractures (esp. Acetabulum) – Require CT Pelvic Fractures Pelvic Fractures Classification Treatment Lateral compression Restore Pelvic Ring – Ramus fracture – Posterior SI Fixation – Sacrum fracture vs SI – Anterior Ex-Fix/Plating Anterior-posterior compression Protected WB for low – Saddle Fracture/Symphysis energy stable fracture – SI Disruption pattern Vertical shear Traction/pelvic sling – Anterior and posterior ring – No longer used 14 Acetabular Fractures Acetabular Fractures Treatment Intra-articular fractures Anatomic reduction Can be associated with Protected weight bearing fractures of femoral neck or femoral shaft Post-traumatic arthritis can result from initial injury to Damage to joint cartilage cartilage occurs with injury (even with perfect reduction) Acetabular Fractures Pelvic Fracture Rehab Insufficiency TTWB/NWB X 3 Older patient without months significant injury history May have skeletal traction short term while May present with awaiting surgery ossification on initial Xray with minimally Watch for PE visible fracture WBAT 15  Young Hip Patient Non-THA Surgery Young patients present with HIP PART 2 hip pain that can be treated prior to THA NON-PROSTHETIC HIP SURGERY Young Hip Patient Young Hip Patient Non THA Surgery Non THA Surgery Nonprosthetic surgical techniques can be used to manage a variety of Intra-articular and peri-articular conditions conditions can cause hip pain, restrict function or predispose to secondary hip arthritis Post-traumatic (Malunion/Nonunion) Pre-arthritic (Dysplasia, SCFE, Perthes, AVN) Intra-articular (Impingement, Labral Tear, Loose Bodies) 16 Young Hip Patient Young Hip Patient Assessment Assessment History History Symptoms Age, occupation, health, personality – Pain (sitting, sleeping, activity) – Mechanical symptoms (locking) – Stiffness Past hip problems-trauma/surgery/family history/risk – Abductor fatigue. factors (ON) What improves/worsens pain, position related? Young Hip Patient Young Hip Patient Exam Select Exams Gait Impingement – Flexion/Adduction/IR Leg Length Apprehension – Extension/ ER hip Hip Strength Bicycle test (abductors) Trendelenberg – Side lying hip motion Range of Motion 17 Young Hip Patient Young Hip Patient Select Exams Select Exams Impingement Impingement – Flexion/Adduction/IR – Flexion/Adduction/IR Apprehension Apprehension – Extension/ ER hip – Extension/ ER hip Bicycle test (abductors) Bicycle test (abductors) – Side lying hip motion – Side lying hip motion ? Position of Comfort Radiographic Evaluation of Young Adult Hip Young Hip Patient Imaging Xrays AP Pelvis – Pelvis (Wt Bearing) Frog lateral MRI (+/- Arthrogram) Dunn lateral False profile CT scan - bony detail 18 Young Hip Patient Young Hip Patient Imaging Imaging Xrays Xrays – False Profile – Cross Table Lateral MRI (+/- Arthrogram) MRI – +/- Arthrogram CT scan-bony detail CT scan-bony detail Young Hip Patient Young Hip Patient Imaging Imaging Xrays MRI (+/- Arthrogram) – Frog Lateral – Labral Tear present in up to 80% of healthy active adults – Dunn Lateral MRI (+/- Arthrogram) CT scan-bony detail 19 Young Hip Patient Low-dose CT Imaging CT scan-bony detail Low-dose CT – No longer the ”tool of the devil” – Radiation similar to 3-4 radiographs ~9x less than standard CT Femoral Version 20  Young Hip Patient Acetabular Coverage Non THA Surgery Femoral Osteotomy Indicated for treatment of: – Proximal Femur Malunion/Nonunion – Post-traumatic OA / hip dysplasia (young pt) – AVN Young Hip Patient Proximal femoral osteotomy (PFO) Non THA Surgery Rehab Protect WB until bone healing Femoral Osteotomy TTWB 6 wks – Post-traumatic Hip Disorders Passive ROM X 6 wks Restore normal anatomic relationships of the hip (length, offset, restoration) 50% WB 6-12 wks, active ROM, gentle strengthening – Proximal Femur Malunion/Nonunion Full WB at 3mos, wean off assist as tolerated, aggressive Femoral Neck (Pauwels osteotomy) strengthening especially abductors Change shear/tension force into compressive load across non-union Avoid Sports x 1 year or longer 21 Hip Arthrodesis (Fusion) Hip Arthrodesis Indications Technique Young (15-30 yrs) active Anterior approach – Dynamic hip screw vs Post-traumatic, infection – Plate (single or dual) – Abductors intact Male, manual laborer Leg Position Normal back and knees – Flexed 15-30 degrees – Neutral abduction – Slight external rotation Hip Arthrodesis Long-Term Pre-arthritic Hip Disease Adequate pain relief Femoroacetabular impingement (in selective patients) DDH (Hip Dysplasia) Slipped Capital Femoral Epiphysis (SCFE) Complications: Perthes’ – Ipsilateral Knee/Ankle – Contralateral hip 90% of patients have structural hip deformity – Lumbar Spine Joint preservation may prolong hip longevity (if performed before cartilage damage/arthritis) Can be converted to THA (difficult) 22 FAI FAI What is it? What is it? Mismatch between Mismatch between femoral head and femoral head and acetabular shape acetabular shape – CAM – Impingement of femur against acetabular rim – Pincer – Labral Tear – Combined – Articular cartilage delamination SCFE DDH Dx/ Rx Etiology Unstable Growth plate Inadequate development of acetabulum Can manifest as knee pain – Deficient femoral head coverage Residual deformity can cause late symptoms secondary Lateral and anterior to hip impingement – Hyperplastic Labrum Flexion, adduction, IR proximal femoral osteotomy Hip subluxation Contour femoral neck junction Secondary arthritis 23 DDH DDH Treatment Treatment Requirements for PAO PAO Technique – Symptomatic DDH without OA – 3 Pelvic Bone Cuts Ischium Ilium – Good Hip ROM Pubic Ramus – Congruent Hip in adduction/flexion – Preserves Posterior Column – Other procedures may be helpful to help contain the femoral head in the hip DDH DDH Treatment Rehab Goals of PAO Protect Bone Repair Weeks 0-6 Weeks 12- 16 – Regain femoral head – partial WB (30lbs) – WBAT with assist, coverage passive, active-assisted – – active strengthening ROM – Medialize hip center of – no active hip flexion rotation Weeks 6-12 Weeks > 16 – partial or 50% – wean off support – active ROM – aggressive strengthening 24 DDH Hip Arthroscopy Rehab Indications Intraarticular and Full recovery takes 6-12 periarticular lesions months – Labral tears – Loose bodies – Cartilage tears Most have FAI / DDH Open or arthroscopic approach can be useful Labral Tear Labral Tear Presentation Etiology Adolescent/young adult DDH – Larger labrum – Mechanical load increased due to shallow acetabulum Trauma or insidious onset Differential diagnosis for mechanical symptoms Groin pain – Snapping Iliopsoas Tendon – activity/position related – Snapping IT Band – Frequently worse when sitting Mechanical symptoms – Catching, locking 25 Labral Tear Labral Tear Non operative Treatment Surgical Rx Activity restriction Arthroscopic or open NSAID’s, pain meds Repair vs Debridement Steroid injection (1X) Correct FAI – Osteochondroplasty Hip strengthening Address Dysplasia 6-12 weeks of treatment (Open) Hip Arthroscopy Young Adult Hip Rehab Summary ROM within comfort limits – CPM used early Important to recognize subtle deformities of the hip WB restriction for 6 wks Labral tear is generally a secondary process – WBAT if labral debridement Non-operative treatment attempted before surgery Immediate PROM/AROM Limit pace of rehabilitation over first 12 weeks 26 Young Adult Hip Summary Limit corticosteroid injections in young patients Surgical treatment should address structural deformity Surgery results are not as predictable if OA is already present 27