From: Rajat Varma
Subject: Subtrochanteric fracture neck femur
Date: Fri, 18 Feb 2005 12:34:00 -0000
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
A. What would you do in your setup in a similar situation?
B. When you see the post op xray ( xray 2 ) what would you do
C. Now with mobile symptomatic nonunion what would you do
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.
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.
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,
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
Melbourne , Australia.