5/31/2018 Ipsilateral Femoral Neck And Shaft Fractures Exchange Nailing For Non- Union Donald Wiss MD Cedars-Sinai Medical Center Los Angeles, California Ipsilateral Neck-Shaft Fractures Introduction • Uncommon Injury • Invariably High Energy Trauma • Typically In Young Male Patient • Associated Injuries Common • Requires Prompt Diagnosis & Rx Ipsilateral Neck-Shaft Fractures Introduction • Incidence 3% - 5% • Difficult To Manage When Displaced • Timing Of Treatment Controversial • Complications High In Many Series 1 5/31/2018 Ipsilateral Neck-Shaft Fractures Mechanism Of Injury • High Energy Trauma • Longitudinal Force • Flexed & Abducted Hip • Flexed Knee Ipsilateral Neck-Shaft Fractures Resultant Femoral Neck Fracture • Basilar In Location • Vertical In Orientation • Displacement Variable • Hard To Visualize • Sub-Optimal X-Rays • Missed Diagnosis Ipsilateral Neck-Shaft Fractures Literature My Case 1982 • Up To 1/3 Femoral Neck Fractures Are Missed • When The Femoral Neck Fracture Is Missed Treatment Options Later Become More Limited And Difficult With Outcomes Worse • Dedicated Hip X-Rays & CT Scans On Initial Trauma Work-Up Decrease Incidence Of Missed Fractures 2 5/31/2018 Ipsilateral Neck-Shaft Fractures Knee Injuries • Knee Injuries In 25% - 50% • Patella Fractures • Femoral Condyles • PCL Injuries • Easily Missed • Pre-Op Exam Difficult • High Index Of Suspicion • Late Morbidity Ipsilateral Neck-Shaft Fractures Treatment Wide Consensus That Fractures Of The Hip Should Take Precedence Over The Femoral Shaft Fracture Ipsilateral Neck-Shaft Fractures Consequences Of The Neck Fracture • Avascular Necrosis • Non-Union • Varus Mal-Union • All Challenging To Treat • Arthroplasty Unattractive 3 5/31/2018 Ipsilateral Neck-Shaft Fractures Femoral Neck Fracture • Non-Displaced Fxs In-Situ ORIF • Displaced Fractures • Direct Anterior Approach • Antero-Lateral Approach • Goal Is Anatomical Reduction Ipsilateral Neck-Shaft Fractures Treatment Alternatives • Reconstruction Nail • Antegrade Nail & Screws @ Nail • Cannulated Screws & Retrograde Nail • SHS And Retrograde Nail • Femoral Neck Screws And Plate Ipsilateral Neck-Shaft Fractures Treatment Alternatives • Reconstruction Nail • Antegrade Nail & Screws @ Nail • Large Screws & Retrograde Nail • SHS And Retrograde Nail • Femoral Neck Screws And Plate 4 5/31/2018 Ipsilateral Neck-Shaft Fractures Treatment Alternatives • Reconstruction Nail • Antegrade Nail & Screws @ Nail • Cannulated Screws & Retrograde Nail • SHS And Retrograde Nail • Femoral Neck Screws And Plate Ipsilateral Neck-Shaft Fractures Treatment Alternatives • Reconstruction Nail • Antegrade Nail & Screws @ Nail • Cannulated Screws & Retrograde Nail • SHS And Retrograde Nail • Femoral Neck Screws And Plate Ipsilateral Neck-Shaft Fractures Treatment Alternatives • Reconstruction Nail • Antegrade Nail & Screws @ Nail • Cannulated Screws & Retrograde Nail • SHS And Retrograde Nail • Femoral Neck Screws And Plate 5 5/31/2018 Ipsilateral Neck-Shaft Fractures Treatment • Anatomical Reduction & Stable Internal Fixation Of The Femoral Neck Fracture Is Mandatory • Attempts To Fix Both Fractures With One Implant Have Been Unpredictable Alho A. Concurrent Ipsilateral Fractures Of The Hip & Femoral Shaft: A Meta-Analysis Of 659 Cases Acta Orthop Scand 67: 19-28, 1996 59 Studies 78% Motor Vehicle Accidents, Median Age 34 Yrs 1/3rd Had Multiple Injuries ½ Had Ipsilateral Knee Injuries Femoral Neck Fracture Mostly Basilar In Location AVN Rate 3%, 99% Healed Locked Nails Gave Better Results Than Unlocked Nails or Plates Reconstruction Nails Gave Equal Results To Separate ORIF Femoral Neck & IM Nails Tornetta P, Kain M, Creevy W. Diagnosis of Femoral Neck Fractures in Patients With a Femoral Shaft Fracture J Bone Joint Surg 89: 39-43, 2007 Developed A Protocol To Diagnose A Femoral Neck Fracture In Pts With A Shaft Fx Dedicated AP Internal Rotation Plain X-Ray; 2mm CT Scan Thru Hip; & Intra-Op Fluroscopic AP And Lateral Views Prior To And After Fixation N=268 Femoral Shaft Fractures Identified 16 Associated Femoral Neck Fractures Using Protocol Conclusion: 91% Reduction In Delay in Diagnosis Compared To Year Prior To Protocol 6 5/31/2018 Ostrum R, Tornetta P, Watson J, et al. Ipsilateral Proximal Femur & Shaft Fractures Treated With Hips Screws & Reamed Retrograde IM Nail Clin Orthop Relat Res 472: 2751-2758, 2014 N=92 40 SHS 52 Multiple Cannulated Screws All Retrograde Nail Femoral Neck Union Rate 98% Femoral Shaft Union Rate 91% Proximal Femoral Mal-Union 5% Avascular Necrosis 1% No Difference Between SHS Vs Cannulated Screws Conclusion: Independent Screw Fixation Of The Femoral Neck Fracture & Reamed Retrograde IM Nailing Leads To High Rates Of Union & Low Complication Rates Ipsilateral Neck-Shaft Fractures Conclusions • Independent Fixation Both Fractures • Often Requires Open Reduction Of Neck Fx • Cannulated Screws Or SHS • Retrograde Locked Nailing • Reconstruction Nails Only In Truly Non- Displaced Femoral Neck Fractures Illustrative Cases 7 5/31/2018 46 Yr Male Involved In High Speed Motorcycle vs Auto Accident Sustaining An Open Grade IIIA Segmental Femur Fracture, Displaced Femoral Neck Fracture, & Acetabular Iliac Oblique Confirms & Complex Acetabular Fracture Obturator Oblique Pelvis “Looks Bad” 8 5/31/2018 I & D Open Femur Fracture; Temporary Two Pin External Fixator, Direct Anterior Approach; 3 Cannulated Screws; Retrograde Nailing And Placement Of Temporary Traction Pin To Manage Acetabular Fx Post-Op CT Scan With 3D Reconstruction Shows T-Type Acetabular Fx CT Pelvis With 3D Reconstructions Show Both Column Involvement 9 5/31/2018 ORIF On Profx Table Via A Stoppa Approach Courtesy Charles Moon MD Radiographs At 6 Months ROM Of Hip 0-100 Degrees; ROM Knee 0-125 Degrees; Healed 10 5/31/2018 41 Yr Old Male Fell 15 Feet From Balcony While Intoxicated Sustaining A Vertical Femoral Neck Fracture As Well As A Grade IIIA Open Segmental Femur Fracture & Ipsilateral Patella Fracture Emergent I & D And External Fixation Of The Femur To Allow For Fixation Of The Femoral Neck Fracture 11 5/31/2018 Direct Anterior Approach With Anatomic Reduction And Fixation With Two Cannulated Screws 3 Days Lateral Removal Ex Fix; Retrograde Femoral Nailing; Two Additional Femoral Neck Screws; ORIF Patella; Follow-Up At 8 Weeks On Crutches Improving ROM Hip & Knee 12 5/31/2018 ROM Hip 0-90 Degrees ROM Knee 0-70 Degrees Lost To Follow-Up 24 Yr Swedish Female Working /Living In LA Related To Film Industry Suicide Attempt Following Jump From 6th Story Apartment Building Hemodynamically Unstable Pelvis Fracture Bilateral Pneumonthorax & Multiple Rib Fractures Unstable Thoracic Spine Fracture and T-6 Paraplegia Bilateral Closed Femur Fractures Displaced Right Femoral Neck Fracture Left Supracondylar Humerus Fracture fC Distraction-Compression Injury & Burst Fracture T-Spine Complete T-6 Paraplegic 13 5/31/2018 Bilateral Femur Fractures & Right Femoral Neck Fracture Reduction, Instrumentation, & Fusion Thoracic Spine T-2 To T- 11 Bilateral Retrograde Femoral Nailing & CRPP Of Right Femoral Neck After Spine Stabilization 14 5/31/2018 Post-Op ORIF Right Femur Closed Reduction & Percutaneous Pinning Of The Pelvis POD #4 ORIF Segmental Humerus, Clavicle, & Calcaneus Post-Op Day 9 15 5/31/2018 Fixation Of All Fractures By Injury Day 11 Air Ambulance Back To Sweden 7 Weeks After Injury It Is Not Enough To Stare Up The Steps; We Must Step Up The Stairs [email protected] 16.