From: Rajat Varma

Subject: Subtrochanteric fracture neck femur

Date: Fri, 18 Feb 2005 12:34:00 -0000

Dear All,

I am presenting this case to survey the current orthopaedic opinion for this common fracture presentation. Please take time to answer the points raised either directly to the list or persanally to me. I will summarise and present the results.

80 years old slim, medically fit lady came last year with subtrochanteric fracture neck femur - Russell-Taylor Type 2B ( fracture of lesser trochanter and piriformis fossa) under a colleague - xray 1
DHS carried out by trainee - xray 2
Lady referred to my clinic by GP 8 months later with leg shortening and severe pain night pain mobilizing non weight bearing with Zimmer frame with painful movements at fracture site. - xray 3

xray 1	xray 2	xray 3

Questions are

A. What would you do in your setup in a similar situation?

• 1. DHS
• 2. DHS with trochateric extention
• 3. DCS
• 4. 95 Blade/Plate
• 5. Gamma Nail ( single lag screw going into the head)
• 6. Long Gamma Nail
• 7. PFN - (two screws going to the femoral head)
• 8. Recon Nail ( long nail with two screws going into head)
• 9. Any other - please specify

B. When you see the post op xray ( xray 2 ) what would you do

• 1. Pray that the fracture heals
• 2. Immediate Bone grafting while retaining the fixation.
• 3. Dealyed bone grafting
• 4. Change fixation - please specify

C. Now with mobile symptomatic nonunion what would you do

• 1. Retain the lag screw and put another plate + / - bone graft.
• 2. change to nail(?which) + / - bone graft
• 3. Change to DCS / 95 bladeplate.
• 4. Total hip replacement - cemented / uncemented.
• 5. Any other please specify

I have made and carried out my choice with mixed final result. I will present that with final discussion.

Please specify whether you are trainee / consultant and the name of the country you practice in.

Rajat Varma FRCS

Consultant Orthopaedic Surgeon

London UK

Date: Fri, 18 Feb 2005 07:30:08 -0600

From: Andrew H. Schmidt

> A. What would you do in your setup in a similar situation?

Normally I have used a 95 degree DCS or blade plate. More recently we have been using trochanteric nails for these. In an 88 year old I would use such a nail to prevent a later periprosthetic fracture. However, this patient has advanced hip arthrosis, so if she was having pain before her fall I would do a total hip replacement with a long stem as primary treatment of her fracture.

> B. When you see the post op xray ( xray 2 ) what would you do

If this patient came to me from elsewhere with this xray, I would warn her of the likelihood of failure, and that revision might be necessary. Again, given her hip arthrosis, THA would be my revision procedure if this were to fail. The timing of surgery would be based on symptoms. >

> C. Now with mobile symptomatic nonunion what would you do

Total hip replacement - uncemented as first choice, but would cement if fixation questionable. Would use cerclage wires around fracture, maybe a strut allograft.

Andy Schmidt

Faculty, Hennepin County Medical Center

Date: Fri, 18 Feb 2005 19:58:30 +0530

From: George Thomas

A. I would use a DCS.

B. Change fixation to DCS, and realign the fracture so that there is bony contact.

C. Change fixation to DCS. If it turned out that the lag screw is not stable in the head due to osteoporosis, I would be prepared to change to a total hip arthroplasty.

Dr. George Thomas,
Consultant Orthopaedic Surgeon,
Railway Hospital,
Chennai, India

Date: Sun, 20 Feb 2005 23:42:13 +1100

From: Peter Hamilton

1. I would use DCS initially but this was always going to be a race between union and implant/fixation failure with that amount of hip arthritis above.

2. Convert to DCS at this stage with reduction.

3. Now 8 months down the track with ongoing symptoms I would do uncemented THJR in this lady

Regards

Peter Hamilton
Orthopaedic Surgeon
Melbourne , Australia.