Date: Mon, 28 May 2001 18:49:31 -0400
Subject: SC Femur Fx below THA
Please see attached pics of an 82 yo woman who lives independently and is a community ambulator s/p low energy fall w/ SC femur fx below a stable uncemented THA (1990).
What would y'all do?
Bill Obremskey MD MPH
University of North Carolina
Dept. of Orthopedics
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Date: Fri, 01 Jan 1904 06:47:46 -0700
From: Chip Routt
Bill-
Looks like SupraCondylar, and IntraCondylar involvements.
I'd fix it.
Chip
Date: Mon, 28 May 2001 19:14:02 -0500
From: Marc F. Swiontowksi, M.D.
Fix it - minimally invasive plate vs carefully measured retrograde nail
Date: Mon, 28 May 2001 19:31:51 -0700
From: John Ruth
Options include a LISS plate, blade plate or retrograde short IM rod. Would not use a DCS due to osteopenia. The plates can overlap the femoral stem and a Synthes cerclage cable an be used with the blade plate. The retrograde IM rod would obviously stop short of the stem leaving a stress riser (significance of which is unclear, research in progress). Take your pick.
Date: Fri, 01 Jan 1904 13:48:32 -0700
From: Chip Routt
Maybe just show us the miracle...the films are 4/7...so I doubt that you're still waiting!
Chip
Date: Tue, 29 May 2001 02:58:57 -0700
From: bruce meinhard
LISS Plate if long enough, or Blade Plate possibly with endosteal substitution palte, finally a DCS. All would work. Delayed weight bearing and No stripping!
BPM
Date: Tue, 29 May 2001 07:12:39 -0400
From: Kevin Pugh
You must fix this fracture, but the THA is the problem. I have done a similar case.
My choice would be reduction of the joint surface, followed by a biologically friendly plating. You must overlap the prosthetic stem and your fixation, with the general guideline being two diameters of the bone.
If you choose a nail, you must leave it short of the stem that far to avoid a stress riser.
Delay the weightbearing, but fix it in a way that you can get the knee moving right away.
Good Luck.
KP
Date: Tue, 29 May 2001 06:47:33 -0500
From: Adam Starr
I'd treat this with an ORIF.
Phil Kregor would probably offer a LISS plate as an alternative to my procedure. I've never used a LISS plate ( and I don't think an 82 year old would be a good one to practice on ) but Phil's results look pretty good.
Another alternative may be immediate TKR, with a "tumor" prosthesis. Might be a quicker operation than a formal ORIF. Speed might be an issue in an 82 year old.
Adam Starr
Dallas, Texas
Date: Tue, 29 May 2001 08:38:40 -0600
From: Thomas A. DeCoster
I've used carefully measured retrograde nail plus percutaneous lag screws in cases like this with reasonable results.
tdecoste
Date: Tue, 29 May 2001 16:51:28 +0100
From: chris wilson
From this side of the Atlantic, where we have only just started using the LISS plate, this device, with its convergent locking screws, does seem to lend itself to this type of fixation, in an osteoporotic intercondylar femoral fracture, much better than a supra-condylar nail(rod), and is less traumatic to apply than a DCS. We have done a number (7) of revision TKA's as treatment for low supracondylar fractures, and these do work well, but the line of bone resection is always higher than you might think from the xrays, and in this case the fracture's proximal extent, which is the level at which the stem would start to have some fixation, looks too high. Would there be case for simultaneous treatment for osteoporosis as well?
Chris Wilson
Knee and Trauma Surgeon
University Hospital
Cardiff, UK
Date: Tue, 29 May 2001 12:03:20 -0500
From: Anglen, Jeffrey
Date: Tue, 29 May 2001 15:52:15 -0400
From: William Obremsky
This patient generated much discussion at our institution whether a retro IMN, blade plate or LISS would be appropriate. The notch is 17 cm from the tip of the THA and I felt that the stress riser could be a problem and would feel terrible if she broke b/t the implants. The THA is so large that a blade or LISS would be difficult to get proximal purchase.
As Chip pointed out the injury was 4-7-01. No miracle, Chip, but her fixation w/ a LISS appears stable at 6 weeks w/ 0-90 knee motion. The proximal fixation is unicortical posterior to the prosthesis. Hope she continues to consolidate.
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Bill Obremskey
Date: Tue, 29 May 2001 23:33:48 -0400
From: Bill Burman
>the stress riser could be a problem
Bill
This looks good on present films - but some theoretical concerns.
Proximal femoral component support seems to be fading (stress shielding vs osteolysis) but it looks solid distally.
Doesn't the introduction of proximal plate screws set up the possibility of crevice and galvanic corrosion at a point in the femoral stem that is already at risk for cantilever mode failure?
If that is an issue and one removes LISS hardware after fx healing, what about stress risers through screw holes in the vicinity of the tip of the prosthesis?
It looks as if there are a few extra drill holes. Is that because of poor purchase in osteoporotic bone or a technical issue with the LISS procedure? I believe it can be difficult to get good fixation of a standard DHS sideplate even under direct vision in some osteoporotic femurs.
Bill
Date: Wed, 30 May 2001 10:00:37 -0400
From: William Obremsky
The extra screw holes are from whirlybird and one repositioning of the LISS when after initial fixation of the plate too posterior. I do not intend to remove the plate, but I think that the screw holes could be a problem if removed. I do not think that the extra screw holes centrally should be a problem.
Bill Obremskey
Date: Wed, 30 May 2001 10:24:08 EDT
From: TRToal
It's just about impossible to get poor purchase with a LISS, even with an osteoporotic femur, because the screws get much better bite on the plate than in the bone. It's a very odd feeling putting the first several on, and requires a leap of faith, but I've yet to lose reduction even in comminuted soft bone.
Tom
