1. Re-written by: Daniel Habashi Intertrochanteric Hip Fractures

2. Intertrochanteric Hip Fracture objectives Incidence Mechanism of injury Physical findings X-ray assessment Classification scheme Treatment goals Treatment options Treatment techniques Complications Outcomes Failure of treatment Salvage procedures

3. Intertrochanteric femur From the extra-capsular femoral neck To inferior border of the lesser trochanter

4. Incidence 250K hip fractures a year Demographics 90% over 65 years of age F>M Peak around 80 y.

5. Etiology Osteoporosis Low energy fall – common High energy – rare

6. Prevention Prevention and active treatment of osteoporosis Fall prevention Minimize fall impact

7. Physical presentation Involved extremity Short External rotated

8. Radiographs Plain films AP pelvis Cross table lateral

9. Special studies CT scan rarely indicated Bone scan – occult fractures, sensitive at 72 hours MRI – occult fractures, sensitive in 1 st 24 hours

10. Classification Multiple classifications Stable vs. unstable Evans Evans-Jensen Muller AO/ASIF OTA Muller AO-ASIF system

11. Classification Stable Resists medial and compressive loads With anatomic reduction and fixation THERE WAS A PICTURE HERE OF A FRACTURE

12. OTA AO/ ASIF Classification 31-A3 Two part fracture Comminuting Fracture enters the lateral cortex Reverse obliquity fracture Unstable

13. OTA AO/ASIF Classification There was also 31-A2 but he changed the slide in a matter of a second so:/

14. Goals of treatment Obtain A stable reduction Internal fixation Good position Mechanically adequate Permit immediate transfers and early ambulation

15. Intra-operative positioning Hemilithotomy position

16. Intra-operative fluoroscopy 2 pictures of it. Nothing important

17. Fracture reduction Neck / shaft axial alignment Translational displacement Anatomic reduction of individual fragments is not necessary Reduction maneuver Traction Internal rotation

18. Implant options Compression hip screw and side plate Intramedullary sliding hip screw Calcar replacing prosthesis

19. Implant positioning Centered in the femoral head ( AP VIEW and LAT VIEW) Etc etc ect

20. Tip-apex distance (TAD) TAD – strong predictor of cut out TAD under 25mm Failure approaches zero TAD over 25mm Chance of failure increases rapidly

21. Implant options Intramedullary Sliding Hip Screw Decreased implant bending strain Potential percutaneus technique Inter-Troch Shaft Reverse obliquity Pathologic shaft fracture

22. Implant options Calcar replacing prosthesis Indications Ewtc etc etc

23. Reverse obliquity fracture

24. Cement augmentation Severe osteopenia Polymethyl methacrylate (PMMA) Improves screw purchase Augment deficient medial cortex Prevent screw cut out

25. Rehabilitation Mobilize Weight bearing as tolerated Etc. etc.etc.

26. Failed fixation Screw cut out Screw barrel disengagement

27. Salvage of failed fixation

28. Outcome Mortality 7-27% 3 months post-op # of medical problems # of post-op complications Function 40% pre-injury ambulatory status 40% ambulatory increased dependence 12% household ambulates 8% non ambulates