Proximal Femoral Fractures Pdf 11
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The majority of proximal femur fractures (PFFs) affects the elderly as more than three quarters of PFFs occur in patients over the age of 75 in Germany [1]. While around 1.3 million hip fractures were reported globally in 1990 [2], the number is estimated to range between 7.3 and 21.3 million by 2050 [2].
With age, the trabecular structure degenerates [15] and, concomitantly, reinforcements like the calcar femorale lose structural integrity. It was hypothesized that the neck-shaft-angle increases with age [16], yet data on more than 8000 neck-shaft-angles showed no significant differences between the age groups [17, 13].
The development of a posttraumatic femoral head necrosis is highly correlated with disrupted retinacular arteries, which pose the main blood supply for the femoral head [22]. In Garden Type IV fractures, all retinacular arteries appear disrupted as a result of gross dislocation [21]. The retinacula of Weitbrecht are intraarticular synovial plicae protecting the retinacular arteries within [23]. Among the anatomical variances, the medial retinaculum is constantly present [23], extending from the base of the lesser trochanter to the edge of the acetabular cartilage (Fig. 2) [23].
PFFs are divided into intracapsular and extracapsular femoral neck fractures, including intertrochanteric and subtrochanteric fractures (Fig. 1). Depending on their location, femoral neck fractures are identified as sub-capital, mid-cervical, and basicervical fractures. Especially in the elderly, the mid-cervical femoral fracture is the most common by far, with a frequency of over 86% [24].
There are three common classifications for femoral neck fractures: The Garden, the Pauwels and the AO classification. First published by R.S. Garden in 1961, the Garden classification is the one most widely used. Femur neck fractures are classified by the fracture displacement based on an ap radiogram into non-displaced (Garden type I and II) and displaced fractures (Garden type III and IV). Garden type I describes an incomplete or impacted fracture, Garden type II a complete fracture without displacement, Garden type III a complete fracture with partial displacement, and Garden type IV a complete fracture with full displacement [25] (Fig. 2).
The Garden classification has only a fair inter-observer reliability when all four types are assessed, but a moderate to substantial one if fractures are only classified as undisplaced or displaced [26]. Fracture displacement correlates with interruption of the vascular supply, as described above; therefore, Garden classification relates to the risk of femoral head necrosis. Due to the disrupted blood supply to the femoral head [21], Garden type IV fractures are not suitable for osteosynthesis. However, if the fracture line is located at the very basis of the femoral neck, it decreases the risk of femoral head necrosis regardless of dislocation, because the fracture might be lateral to the vascular supply.
AO classification of femoral neck fractures. AO 31-B1 includes impacted fractures. With decreasing impaction from grade 1 to grade 3, B2 consists of a larger femoral head fragment with a fracture line increasing in slope from grade 1 to grade 3, and B3 describes a small head fragment with increasing dislocation and instability with increasing grade
If non-NSAIDs and opioids are not sufficient, femoral nerve blocks may be considered [32]. Guay et al. stated in a Cochrane review that there is moderate quality evidence for reducing pneumonia risk, decreased time to first mobilisation, and cost reduction in pain medication after single-shot blocks [33]. High-quality evidence suggests that a regional blockade reduces pain on movement within 30 min after block placement [33].
For the screening of delirium in hospitalised older people, the 4AT is a sensitive and specific tool which is validated for hip fractures [46]. To determine mental status changes, it is important to establish a baseline status, for example using routine screening at admission.
If delirium occurs, it is important to search for a possible reason in need of treatment, such as electrolyte derangements, metabolic derangements, infection, organ failure, pain, or anticholinergic load. With the help of an anticholinergic burden scale, e.g., the anticholinergic drug scale, inappropriate medication in elderly patients can be identified [47]. Using drugs with anticholinergic properties in the elderly increases the risk of delirium, cognitive impairment, falls, fractures, and mortality [48]. We recommend evaluating the indication and modalities of drug therapy for delirium together with a geriatrician (Table 2).
Both in intertrochanteric and subtrochanteric fractures, the treatment of choice is intramedullary nailing as it decreases soft tissue damage and permits early weight bearing. For intertrochanteric fractures, the choice of implant depends on the stability of the fracture pattern defined by the lateral cortical wall [50]. Extramedullary devices like the sliding hip screw can be chosen if the lateral cortical wall is intact [50], making a thorough evaluation of the fracture pattern essential when an extramedullary device is considered.
Cheng and Sheng compared eight treatment options for intertrochanteric fractures [dynamic hip screw, compression hip, percutaneous compression plate, Medoff sliding plate, less invasive stabilisation system, gamma nail, proximal femoral nail, and proximal femoral nail anti-rotating (PFNA)] and identified PFNA as the preferable surgical method with fewer blood loss and high functional outcomes, according to the Harris hip score [51]. When using intramedullary nails, the use of a helical blade in comparison to a lag screw is associated with a higher rate of collapse of the neck-shaft angle and the concomitant dislocation of the screw (cut-out) in the femoral head [50].
Subtrochanteric fractures are a less common type of hip fracture. In subtrochanteric fractures, intramedullary nailing (long nail) is considered the gold standard, because it decreases operation time, fixation failure and length of hospital stay in comparison to extramedullary devices [52].
Femoral neck fractures can either be treated with osteosynthesis, total hip arthroplasty or hemiarthroplasty. In patients with more than one comorbidity above the age of 70, there is an 83% risk of secondary fracture dislocations when treated conservatively [55], making surgery the treatment of choice for elderly patients. When choosing the implant, two main aspects need to be kept in mind: older patients are less likely to follow weight-bearing restrictions [56], while, on the other hand, the indication for osteosynthesis needs to be carefully considered. Due to biomechanical aspects, according to Pauwels classification, any femoral neck fracture classified as type I or II is an indication for internal fixation. Due to the blood supply of the femoral head, femoral neck fractures classified as Garden type III and IV are, in most cases, not suitable for osteosynthesis. Dislocated femoral neck fractures are related to a high incidence of interrupted blood supply of the femoral head (as described above), and therefore, predisposed for fixation failure. Existing osteoporosis and age-related changes in bone structure might lead to an increased risk of non-unions in elderly patients [57]. Osteosynthesis is, therefore, suggested in either biologically young patients with non-dislocated fractures or as a salvage option, if the patient is bed-bound and operative therapy is only indicated for pain management.
There is good evidence that in hip arthroplasties, cemented implants lead to less postoperative pain and thereby better mobility [59]. A cemented femoral stem leads to a better fixation in osteoporotic bone [60]. Because no cortical press-fit needs to be achieved, only a reduced stem preparation is necessary, leaving a thicker cortical wall. This results in a potentially reduced periprosthetic fracture risk and lower loosening rates. In a German registry study, Konow et al. showed a two times higher risk of a periprosthetic femoral fracture in uncemented versus in cemented stems with a significantly increased risk for patients above the age of 60 when uncemented stems were used [61]. Therefore, a standard procedure should include a cemented shaft and, depending on the patientĀ“s activity, a hemiarthroplasty or a total arthroplasty should be chosen. In active patients, a total arthroplasty is the implant of choice due to a better functionality and lower long-term reoperation rate in comparison to hemiarthroplasty. However, total hip arthroplasty might be linked to a higher rate of dislocation [60]. Procedure-related factors such as the surgical approach, the positioning of the components, the soft tissue tension, the surgeonĀ“s experience, but also implant-related factors play a major role in the risk for dislocation following total hip arthroplasty [62]. Sarcopenia, the loss of proprioception, and an increased risk of falls are described as typical risk factors in the elderly [62]. For patients who are not able to follow precautions to lower the risk of dislocation, hemiarthroplasty might be the better option. For those with an elevated risk profile and suitable bone quality, a non-cemented shaft should be considered to lower the risk of bone cement implantation syndrome during the operation. Risk factors for suffering from bone cement implantation syndrome include impaired cardiopulmonary function, grade III and IV ASA levels, pre-existing pulmonary hypertension, poor pre-existing physical reserve and bony metastases [63].
The Dorr type and the cortical thickness are key factors in estimating the risk of an intraoperative fracture when placing the prosthesis and can thus help guiding the choice of the fixation method. The Dorr description of the proximal femoral morphology correlates with a low cortical thickness index [64]. In comparison to type A, Dorr type B and C indicate a higher risk of intraoperative fracture [64]. 2b1af7f3a8