Evolving Technique or Pass: The Role of the Proximal Femoral Locking - - PowerPoint PPT Presentation

Evolving Technique or Pass: The Role of the Proximal Femoral Locking Plate in Subtroch Femur Fractures

Gil R. Ortega, MD, MPH Sonoran Orthopaedic Trauma Surgeons Orthopaedic Trauma Director, Mayo Clinic Arizona Residency Program Vice Chair, Department of Surgery, Scottsdale Osborn Level 1 Trauma Center, Scottsdale, AZ, USA

Disclosures

• Founding Member, Orthopaedic Board of

Advisors: Carbofix

• Founding Member, Orthopaedic Board of

Advisors: Artross Nanobone

• Consultant: Smith and Nephew

Why Plate a Subtroch?

PFLP of Subtrochs

• Some studies report implant failure due to

loss of the posteromedial bone support and recommend anatomical reduction

• Other studies report excellent to good

results with indirect (biological) fixation without anatomical reduction

Why You Should Consider PFLP for a Subtroch

• Short-term clinical results of PF-LCP fixation

for subtrochanteric fractures using both conventional and biological fixation

• Forty six patients with

comminuted subtrochanteric fractures

• Treated by either conventional (open, direct) or

biological (indirect) reduction method and internal fixation with PF-LCP

Why You Should Consider PFLP for a Subtroch

• 44 cases continued to final follow-up

– 23 open fixation group and 21 biological fixation group

• Open group

– Greater blood loss (756±151 vs. 260±39ml; P<0.0001) – Longer operative times (129±16.9 vs. 91±8min; P<0.0001) and incisions (s) length (20.4±3 vs. 13.4±1cm; P<0.0001) – More patients needed blood transfusion in open group (11 patients vs. six in closed group; P<0.0001) – Biological group demonstrated longer fluoroscopy time (80.9±7.3 vs. 47.2±5.8sec.; P<0.0001)

Why You Should Consider PFLP for a Subtroch

– For each group, one case of implant failure was recorded – Low patient compliance was detrimental factor for implant failure in both cases – No major difference for healing rate (open group; 18.3±3.7 vs. biological group16.5±4 weeks; P<0.058) and for functional outcome (open group; excellent/good: 54%/37%, biological group; excellent/good: 57%/33%; P=0.766)

• El-Desouky II1 Clinical outcome of conventional versus biological fixation
• f subtrochanteric fractures by proximal femoral locked plate. Injury. 2016 Jun;47(6):1309-17.

doi: 10.1016/j.injury.2016.03.016. Epub 2016 Mar 17

Why You Should Pass on PFLP for a Subtroch

• Comparison of a cephalomedullary nail (CMN),

a proximal femoral locking plate, and a 95° angled blade plate in comminuted subtrochanteric fracture model

• Comminuted subtrochanteric femoral fracture

model was created with 2-cm gap below lesser trochanter in 15 pairs of human cadaveric femora confirmed to be nonosteoporotic

Why You Should Pass on PFLP for a Subtroch

• CMN construct withstood significantly more

cycles, failed at significantly higher force, and withstood significantly greater load than either

• f plate constructs (P < 0.001)
• PFLP equal to blade plate
• Varus collapse was significantly lower in CMN

construct (P < 0.0001)

• Forward et al. A biomechanical comparison of a locking plate, a nail, and a 95° angled

blade plate for fixation of subtrochanteric femoral fractures J Orthop Trauma. 2012 Jun;26(6):334-40. doi: 10.1097/BOT.0b013e3182254e

Why You Should Pass on PFLP for a Subtroch

• Retro study, 10 cases with 7 failures

– Three acute peritrochanteric fractures – One case failure of compression hip screw – Three nonunions – Implant failure in 4 cases – Loss of fixation in 3 cases with varus collapse and implant cutout – Five of 7 failures within first 3 weeks – All failures within 40 days

– Tejwani et al. Failure of proximal femoral locking compression plate: a case series J Orthop

• Trauma. 2011 Feb;25(2):76-83. doi: 10.1097/BOT.0b013e3181e31ccc

Why You Should Pass on PFLP for a Subtroch

• 18 patients with PFLP
• At 3 months postop, four patients had varus

collapse

• At 6 months postop, two patients had cutouts

and one other patient had implant failure

• 7 of 19 patients requiring reosteosynthesis or

prosthesis implantation due to secondary loss of reduction or hardware removal

• C. Wirtz et al

Why You Should Pass on PFLP for a Subtroch

• Biomechanical comparison of PFLP, DCS, and PFN in

synthetic bones with gap osteotomy for comminuted subtrochanteric femur fracture

• Fixation strength (load or moment to failure) of LCP-DF

(1,330 N; range, 1,217-1,460 N) was 26.6% and was greater in axial loading compared with DCS (1050.5 N; range, 956.4-1194.5 N) and 250% less in axial loading compared with long PFN (3633.1 N; range, 3337.2-4020.4 N; p=0.002)

• Ultimate displacement in axial loading was similar for LCP-

DF (18.4 mm; standard deviation [SD], 1.44), DCS (18.3 mm; SD, 3.25), and long PFN (16.7 mm; SD, 1.82)

Why You Should Pass on PFLP for a Subtroch

• PFLP stronger than the DCS but Nail strongest
• Kim et al. A biomechanical analysis of locking plate fixation with minimally

invasive plate osteosynthesis in a subtrochanteric fracture model. J Trauma. 2011 Jan;70(1):E19-23. doi: 10.1097/TA.0b013e3181d40418

Why You Should Pass on PFLP for a Subtroch

• Comminuted subtrochanteric femur

fracture was created with a 2-cm gap below lesser trochanter in 15 synthetic femora

• Compared Blade plate, New PFLP, and Old

PFLP

• N-PFLPs were significantly stiffer than

blade plates and O-PFLPs (P = 0.01) and had trend toward withstanding more cycles before failure (P = 0.06)

Why You Should Pass on PFLP for a Subtroch

• All five O-PFLPs demonstrated catastrophic

fatigue failure before completion of protocol

• One each of blade plates and N-PFLPs

failed to complete the protocol (P = 0.04)

• N-PFLPs were shown to have

biomechanical properties that were at least equivalent to those of blade plate

• Floyd et al Biomechanical comparison of proximal locking plates and blade plates for the treatment
• f comminuted subtrochanteric femoral fractures.J Orthop Trauma. 2009 Oct;23(9):628-33. doi:

10.1097/BOT.0b013e3181b04835

Conclusion

• There is more evidence that shows

you should pass on using a PFLP for a Subtrochanteric femur fracture and that a Cephomedullary Nail is likely better clinically and radiographically

Thank You