4/26/2018
Whats Best for Grandpa? Nail Him!
Bruce H. Ziran, MD FACS Director of Orthopaedic Trauma The Hughston Clinic at Gwinnett Medical Center Atlanta, Georgia
Disclosures
• Industry Relationships • Synthes, Acumed, Citieffe • Off label use: None • All products FDA approved
Dogma vs. Propaganda vs. Common Sense • Dogma: “An authoritative principle, belief, or statement of ideas or opinion, especially one considered to be absolutely true”
• Dogma: The CHS is the “gold standard” of hip fracture fixation and proven. There is no need to consider an alternative and more expensive implant.
1 4/26/2018
Dogma vs. Propaganda vs. Common Sense • Propaganda: “The systematic propagation of a doctrine or cause or of information reflecting the views and interests of those advocating such a doctrine or cause”
• Propaganda: Industry promotes the “benefits” of the IMHS because it is 2-3 times the cost
Dogma vs. Propaganda vs. Common Sense
• Common Sense: Good judgment in practical matters • Good judgment comes from experience, that comes from bad judgment
• Common Sense: Some fractures are better treated with CHS but most will benefit from the IMHS
• My experience • 1988-1998: Exclusively CHS • 1998-2011: Exclusively IMHS • 2011-present: common sense….
State of Affairs: Consensus • Little clinical difference between CHS and IMHS amongst the plethora of studies in print…..
• Cut-out rates remain low when TAD < 25mm
• There has been a shift towards IMHS past 20yrs • CORR 2015 Survey of 3786 US surgeons • 68% IMHS, 19% CHS, 13% both • Ease of use and perceived better outcome
• The CHS may be cheaper….at first.
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The Fractures and The Issue
• Stable fractures: • 75% load sharing by bone • Any “well done” implant works • Unstable fractures • Degree of instability • Ability to reduce • Quality of bone • Demands of patient • Ability of surgeon
Common Sense?
• A1: CHS easier
• A2: IMHS
• A3: IMHS
What Would You Do With These?
3 4/26/2018
What To Expect With CHS
Why? Its pretty simple
Tencer, ’84 Lundy, ‘99
Comminution Leading to Collapse
4 4/26/2018
No Medial Buttres or Bone Stability
cut out
What Does Literature Say? • Henzman et al. Orthopaedics 2015 • IMHS: Lower risk of conversion to THA • Guerra et al. Injury 2014 • At 6 mos: DHS pts less function than IMHS • At 1 yr: Functional recovery scores were similar • Parker et al. Cochrane Review 2010 • Inconclusive data. • Most likely operator dependence or bias • Ziran et al (Orthopaedics 2009) • Better FIM scores during in-patient stay • Bhandari et al. JOT, 2009. Meta-analysis (N=1585) • Previous issues resolved with technique. No outcome differences
Literature • Jiang SD et al, Meta-analysis. 2008 • 1344 patients. No difference between either implant • Utrilla et al. JOT 2005 • No significant difference except walking ability better with IMHS • Leung KS et al (JBJS 2005) • IMHS had shorter convalescence • Sadowski et al (JBJS 2002) • A3 frx better with IMHS versus any 95 degree implant • Adams C et al (JOT 2001) • IMHS had higher revision, cut out and shaft fractures
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And About That Cost Issue….. • Swart et al. JBJS 2014 • Cost effective analysis • Depends on “failure rate” • If DHS failure <1% its more cost effective • If DHS failure >5% its less effective • DHS more cost effective for A1 • IMHS more cost effective for A3
• Isnt that what I said before???????
What Do I Say Now?
• My colleague if full of it…… • He likes to hear himself talk……
• For 2 Part stable fractures where the fracture line exits near the tip of GT the CHS is implant of choice
• For ALL OTHERS the IMHS is implant of choice
For every one of these…..
6 4/26/2018
There is probably more of these…….
The Moral of the Debate
• If you want to nail a good result, go to this surgeon (who uses a nail)
• If you want to get screwed, then go this this surgeon
Thank You
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What I Expect Reisman to Say
• “Yeah, yeah, yeah. The literature may say that but in my hands……”
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