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Name:
Nailing of Subtrochanteric Fractures
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Nailing of Subtrochanteric Fractures
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
HITESH GOPALAN: Good evening everybody, and welcome all of you to this live program of orthopaedic principles. Today, our guest of honor is Dr. Ashok Gavaskar from Chennai, India. Dr. Ashok Sunil Gavaskar is currently the clinical leader of orthopedics and heads joint reconstruction trauma services at the Rela Institute and Medical Center in Chennai, India. He is a distinguished member of the AO Trauma Technical Commission as part of the Asia-Pacific expert group.
HITESH GOPALAN: He's an honorable member of the International Advisory Board for General American Academy of Orthopedic surgeons. He also serves as an associate editor for the Indian Journal of Orthopedics and the European Journal of Orthopedic Surgery and Traumatology. So today, it's my great honor to introduce you to Dr. Ashok Gavaskar from Chennai, India. Over to you Ashok.
ASHOK GAVASKAR: Thank you. Thank you Hitesh for the introduction and thanks for the opportunity to speak on your platform as well. So can I go again?
HITESH GOPALAN: Yes, please. Yeah OK.
ASHOK GAVASKAR: So I will be speaking to you about the
ASHOK GAVASKAR: Nailing in trochanter fractures. I have just titled it as reduction and fixation go
ASHOK GAVASKAR: hand in hand because that truly does. And I would focus predominantly on select problems and surgical tips and techniques that you can use to kind of nail successfully. All kinds of subtrochanteric fractures that you might encounter in your practice. So these are my disclosures. None of them are probably relevant to this talk.
ASHOK GAVASKAR: So the learning objectives for this webinar would be to learn more about nailing of subtrochanteric fractures, focusing on how to understand the deforming forces that act to the proximal femur that you might have to handle when you try to nail this fractures. We will review the common displacement patterns in proximal femoral fractures in general and how they influence your surgical technique. We will also understand the common problems that you might face during nailing of subtrochanteric fractures and how to overcome them.
ASHOK GAVASKAR: I'll tell you how to perform various, minimally invasive and open reduction techniques that are often required when you deal with these fractures and also select tips and tricks when it comes to nailing of this problem fractures. So first of all, the question is like, when there are so many difficulties, why choose nailing of a subtrochanteric fracture? Why should we do it?
ASHOK GAVASKAR: Why not do a different option? The first thing is the biomechanical advantage that a nail will give you. We all know that with regards to the lever arm and the forces acting upon the implant and also the fracture, the nail gives you a favorable loading pattern because it is centered along the medullary cavity. And so when you have a medial defect or a lateral wall failure, a nail being in an medullary location gives you an enormous advantage with regards to resisting the forces across the fracture.
ASHOK GAVASKAR: Nail also tends to be a more kind of a load sharing implant so it tends to load the fracture if you allow the weight bearing and also doing dynamic forces that act along the hip during range of motion. So being a load sharing implant definitely helps with regards to loading patterns across the fracture and also in healing and also allows the patient to be active and use this hip joint during the course of fracture healing.
ASHOK GAVASKAR: And then, when you choose a nail, it also helps you to do it in a minimally invasive manner though it may not be always possible, especially in sub-troch fractures. This is very much a realistic option in select fractures at least where you can do a closed reduction or even a minimally invasive percutaneous reduction so that you don't disturb the biology of the fracture too much.
ASHOK GAVASKAR: What is nailing a sub-troch fracture really easy? Definitely, no. Especially when it comes to an A3 fracture, nailing it is definitely not easy. And if you don't nail it to well, you are bound to fail most often and failures can result in a lot of problems, especially loss of bone, that might make future reconstructions definitely more difficult.
ASHOK GAVASKAR: And if you look at the literature, the amount of malunion, especially like, look at the non-union things like they will definitely fail. Even if you succeed, the amount of varus malunion you get in the proximal femur is tremendously high, around 33% and these patients never do normal. They might still have a hip that is functioning, but they do have a lot of limitations. And even in this series, patients who got to open reduction did better in terms of achieving a normal proximal femoral anatomy that you need to keep in mind as well.
ASHOK GAVASKAR: So how to prevent failures when you nail a sub-troch fracture. You have to remember mechanics are the key, though biology is important. When you think of treating a sub troch fracture, you need to restore mechanics, that is paramount. You have to remember union is not the only goal. You need to make the proximal femur look like a proximal femur
ASHOK GAVASKAR: so that it works seamlessly as it used to before the injury. Remember, reduction is paramount, otherwise most sub-trochs will fail whether you nail or flame, you need to restore length, alignment and rotation and make sure you do not leave your sub-troch fracture distracted, this is bound to fail as well. So if you want to prevent failures, you need to restore the proximal femoral mechanics.
ASHOK GAVASKAR: So why are nail malalignments so common when you nail a sub-troch fraction, why does this happen? Most often it happens because we end up adding a wrong entry point. This happens in turn because you have not got a good reduction. So when you nail a sub-troch fracture, the main difficulty is is this the failure to control the small proximal fragment? That is what predisposes to all our problems. You can get a mild reduction, which in turn will predispose you to the wrong entry point and then subsequent further malalignments.
ASHOK GAVASKAR: So if you look at general, if you look at the main points, why nailing a sub-troch fracture is difficult, one is the deforming forces, you know that the proximal femoral fragment in this fractures will be flexed abductor and externally rotated, and this will remain so even when you put the patient on traction most of the time. So you need to go in there, get this fracture fragment reduced before you can start your nailing procedure,
ASHOK GAVASKAR: otherwise, more often than not, you will end up with problems because your nail will not reduce the fracture, which is mal-reduced. So without reduction you do not get a good nail entry. So if you want to reverse this pattern, it will never, ever work, so it's always reduction first and reduction can be very, very difficult on this short fragment. Second, as I said, is that the proximal fragment, which is bound to tremendous amount of deforming forces, is also short most of the times.
ASHOK GAVASKAR: And when it is short, the more difficult it makes for us to achieve a reduction. When you have a fracture, the subtrochantric region that is slightly lower, it tends to be more like a proximal femoral shaft fracture and then the reduction is much more easier but when you go higher, it is much, much more difficult because all these muscular forces, the abductors, external rotators and the flexors tend to be concentrated on that small fragment, making the reduction extremely, extremely difficult because it is multi planar.
ASHOK GAVASKAR: So, and as I said, this fracture will not reduce the fracture and you have to rely on different means. And will my nail reduce a fracture? No, because the proximal fragment is too short and sometimes the posterior segment of the proximal fragment is often much shorter, so you will not have an inflammatory reduction tool available and you will need to rely on some of these techniques.
ASHOK GAVASKAR: And a third problem is nailing processes as such can malalign even a well reduced fracture. So if you look at this example, it appears to be well reduced in terms of reduction on the AP view, but your nail injury can actually malreduce it. This happens because of mismatch in the angle between the nail and the next sharp angle and when that happens you will predispose or shift the proximal fragment into varus, causing a mild reduction.
ASHOK GAVASKAR: So a lot of things can happen over nailing of the sub-troch fracture that has to be handled. And last thing is, like sometimes the anatomy itself might make it very difficult. That is the case with atypical fractures. If you look at this example, you can see that the proximal femur is not normal, you can see the medullar cavities closed and you can see a lot of endeostomy remodeling on that proximal femur
ASHOK GAVASKAR: and if you are going to nail this, this can be really, really difficult and often you can end up in mild reductions like this. For atypical fractures, nailing is a great choice, but can be really difficult unless you follow certain principles and tricks. Otherwise, these can be really tough on you and also on the patient. So we and from my preceding slides, you would have understood that with regards to successfully treating sub-troch fractures, it is all about reduction.
ASHOK GAVASKAR: Unless you get a reduction, you will not be successful, and even when you get a reduction, you still have to complete nailing without losing reduction, that is a different task by itself. So I'll just take you through different case examples focusing on reduction techniques predominantly.Of course, like my pressure to open a sub-troch fracture is very, very less but in spite of that, I think like a lot of times if you can spend some time, most of these fractures are amenable for minimally invasive reduction techniques that you can perform successfully.
ASHOK GAVASKAR: So I'll take you through various reduction options that are possible and also tell you some tips and tricks how to do it. So if you look at this case example, this guy is an elderly gentleman who had a low velocity fall and had a spiral sub-troch fracture that looks like this. So if you kind of put him on fracture table, we do this practice on fracture table most of the times, but I often do it without traction.
ASHOK GAVASKAR: So this is how he looks on traction and this looks to be reasonably acceptable on AP view. But is this really right to go ahead with the nailing? I don't think so, because if you look at the AP view carefully. If you look focused on the greater trochanter, you can see that the greater troch is definitely not appearing as a point. This indicates that the greater troch or the proximal fragment is still externally rotated and you do not have an ideal entry point.
ASHOK GAVASKAR: So you need to correct it so that you can get a more medial and correct entry point, and if you look at the lateral, it looks OK, sorry, it looks off. I'm not able to see it on the screen. The lateral looks off, so definitely on both views it is not ready to start your daily process. So what do you do? We can go ahead and do minimally invasive reduction technique to get your reduction right.
ASHOK GAVASKAR: So this is an interesting technique, a very simple one as well from Korea. These guys describe a simple surface technique where you can correct external rotation of the proximal fragment. So what these guys do is they use an artery clamp, go through the vastus, and then slide the artery clamp over the proximal femoral fragment anteriorly and then lever it into an internal rotation kind of thing.
ASHOK GAVASKAR: So what happens is like the artery clamp uses the muscle attachments under the lateral side to bring in internal rotation of the proximal fragment that is externally rotated. So this is a very easy technique to do and good thing is, is this does not interfere with your daily process, you can also do a k-wire or a shaft spin into the proximal fragment to control that
ASHOK GAVASKAR: but the problem is you have to really place them correctly. so that your nailing process goes on in there. But this happens on the surface so it doesn't interfere with the nailing process at all, and as you can see on the left, they mainly just from their own articles, you can see that once you have artery clamp is in place, you can see that the greater troch now appears in profile as a point and you can go slightly medial to the right entry point and start nailing this one.
ASHOK GAVASKAR: So this is a great precursor and I use it all the time and a lot of times this one helps me to control the flexion deformity as well, not just the external rotation. So sometimes this will be the one reduction tool that I will use in a sub-troch fracture. So this is a great tool to use actually, it takes no time and no fluoroscopy is required. So you've got your AP reduction right, but your arthro lateral still does not look good.
ASHOK GAVASKAR: So at this point therefore you can see the Arctic lamp lying over the proximal fragment, but here my flexion is not so corrected. So at this point, a lot of us will think like, can I go again and try to nail it along the axis of the proximal segment and then get it to the distal segment? I think you should resist because as you can see, the proximal segment posterior is extremely short and your nail will never work effectively as a joystick here.
ASHOK GAVASKAR: So what next? Our go to would be to use multiple clamps. You can use pointed clamps that you can place them in both lateral and AP plates and you can also use the serrated bone clamps as well and often you require a multiple of tools. Our go to tools would be the pointed clamps, the bone hooks and the ball spike pushers along with the artery clamp anteriorly.
ASHOK GAVASKAR: And most often with the combination of these tools, you will be able to kind of reduce your fracture, as we have shown here in one of our examples and then once that is done, you can go ahead and nail your fracture, which will go on to heal in an anatomical manner. So this is an example of some kind of surface reduction tool that you can use in a sub-troch fracture. So if you look at this guy again, for example, just to highlight the utility of the anterior artery clamp.
ASHOK GAVASKAR: 22 male with a high velocity injury, he's got kind of a low sub-troch, but with significant amounts of communition.
ASHOK GAVASKAR: And if you look at the c-arm images, this is how it looks under a little bit of traction. As you can see, the AP looks kind of OK, but it is still externally rotated, as you can see, by the lesser sub-troch profile and the lateral looks completely off. So again, the same technique, we go again and use an artery clamp, you can see that we are bringing the internal rotation into the proximal fragment now.
ASHOK GAVASKAR: And you can see on the lateral view also I'm getting my proximal fragment in line within the main distal shaft fragment. So once I've gone, once I've got that, I can go ahead and get my nail entry done under carefully, under fluoroscopy and gradually I can reduce this fracture absolutely closed and get my nail inside and that is how it looks like at the end of the procedure. So sometimes, as I said, this would be the only reduction tool that I would require to reduce a sub-troch fracture, which is quite easy.
ASHOK GAVASKAR: So what other clamps that you can use? You can use a lot of other clamps as well. So this was a 37 male, but that's kind of a trans-troch. entry fracture, as you can see, he's got a commination on the lateral side as well and this is not going to reduce interaction and without reducing this one, you will never get your nail entry right so if you look at this, this is what it looks like.
ASHOK GAVASKAR: If I'm going to kind of go there with this picture and start nailing it, there is a high possibility that I might go through the fracture and compromise or blow out the lateral wall. So these fractures require reduction and you can reduce them almost anatomically with the clamp so that you will get a right entry point and also preserve the lateral wall. So go again, a couple of pointed clamps on the lateral wall, hold them in place and then nail them,
ASHOK GAVASKAR: they do absolutely well. And in the young patients, this is the kind of nail that you will require. You don't require the high profile nails like the proximal femoral nails that you use in the elderly patients because like they will take up a lot of bone and can make the process much, much more difficult. So what you require in this practice, many patients, is the type of nails which have a much lower profile.
ASHOK GAVASKAR: So there's another male, a 44-year-old with a comminuted A3 type fracture. Again, as you can see, there you have a fracture on the lateral wall as well, which appears separate fragment. So again, if you look at it on the AP, it looks reasonable, but on the lateral plate, you have a mild reduction. Again, like here we go again for a small incision and then the sagittal plane goes there, reduce it plane anatomically and then go ahead and nail it , so you can use a different, different varieties of clamps.
ASHOK GAVASKAR: So depending on what kind of a fracture pattern we have. So what about wires and cables? They are great tool as well. In select sub-troch fractures, we use them in spiral sub-troch fractures and also some fractures which are long oblique tools, kind of like all them reduced when we nail our fractures. So they can be used as a biologically effective tool, You do not have to have concerns about it in terms of affecting the blood supply of the periosteum.
ASHOK GAVASKAR: Several experiments have shown them they are effective and they are biological as well. There are percutaneous tools as well, which you can use to pass them elegantly and hold your fracture reduced till you nail it. So this is one of the case, like the same one, the same case, which we have shown here, a single wire and then nailed effectively, which went on to heal uneventfully at three months.
ASHOK GAVASKAR: This was another case in an elderly male, the communuted sub troch and as you can see there, you can see a butterfly comminution on the medial side and all the typical deformities that you will encounter in a subtroch fracture and this is what it looks like. So we are probably like, I could have gone ahead without wiring this as well, because I don't think that fragment actually helps in kind of stabilizing it, but
ASHOK GAVASKAR: some so, again, the same technique you can see the arctic lambp coming in and then my entry and I felt my, my, my reamer was going into the medial side varsus that because that is a pathway of the least resistance, your nail kind of tends to go in medial side through the comminution. So I had to start up like wire this arms so that I can get my nail centered in the medular cavity and not getting the proximal fragment into varus.
ASHOK GAVASKAR: So just a single wire toward that butterfly fragment, which is part of both the approximate and the distal segment. So that is one problem. So once we have done that without your nail in place and then it looks pretty well reduced in both planes. So another case. Obese patient with a BMI of 37, a similar spiral comminution then this was considering his obesity, we did it in lateral position. Lateral position does make certain things easier, especially the entry and certain amount of reduction as well
ASHOK GAVASKAR: but it makes a lot of other things difficult too like access to fluoroscopy and sometimes like even the entire nailing process can be a little bit difficult to do So like, I prefer to do them in supine position but lateral position can be useful in patients, especially one obese, and I also use them in revisions as well. So in this case, like we used two wires, one was to reduce the lateral wall to the proximal fragment to, in order to contain the nail.
ASHOK GAVASKAR: So if you have a lateral wall fracture and if you want to keep that, and if you want to use a nail, you have to make sure the nail is contained. So if you have a lateral wall fracture that is undisplaced, attached to soft tissues heal well, then you do not have to worry about it as long as your nail is contained. But if you have a lateral wall that is kind of floating, going, drifting posteriorly or migrating superior, then those Lateral walls should be put back in place and stabilize so that your nail will be contained in the proximal segment and then other wire to hold and reduce the main fracture line.
ASHOK GAVASKAR: And then it goes on to be fixed, fixed and heal well at 3 weeks, three months. So what about other reduction techniques? Joysticks are a great tool as well, I use them quite, quite a lot, especially in fractures that are short, oblique and transverse where I can't use clamps very effectively. So if you are trying to reduce this fracture in a closed or a minimally invasive manner, joysticks are a great way to do it.
ASHOK GAVASKAR: So you can use joysticks in both planes in either from lateral to medial to control abduction and also rotation and also in the flexion extension deformity can be controlled by passing a joystick in the anteroposterior plane. So here if you can look at it, there's a joystick on the medial lateral plane to control abduction, and once if you are pushing them carefully, much anteriorly, you can go again and the nailing can be done without any hindrance.
ASHOK GAVASKAR: Here are a few more reduction techniques that have been used to control and center the nail in the proximal fragment with the posterior blocking pin as well. And once done, this can go on to heal without any problems. So another case to illustrate an anteroposterior joystick, if you can look at this again, the proximal segment in the fracture line is pretty much a short oblique or a transverse bit kind of a comminution in the medial side.
ASHOK GAVASKAR: So this is what it looks like on the APM lateral view. So you can see the AP looks pretty much aligned, but the lateral you can see that is a flexion deformity. So here I don't need a joystick from the medial lateral plane because that looks all right. But the flexion extension deformity, if you want to correct it, joystick is a great tool. So what I typically do is put a joystick medially into the lesser troch region, which has got great hold and you can do it in a safe manner by using a sleeve.
ASHOK GAVASKAR: And once it is in place, you can kind of use the joystick to correct the flexion deformity and go ahead with your nailing because this wire is in the region of the lesser troch, well outside the intramedullary cavity. So it doesn't come into the picture when you start nailing your fracture. So this is what it looks like. You can see the location of the joystick over there on the medial side.
ASHOK GAVASKAR: So once you connected to the deformity, you can go again, get your nail and this is what it looks like. So joystick placement, if you want to use them, choose your fracture. It works well in antroverse and chart oblique fractures and depending on the deforming force, you may choose to use one or two joysticks medial-lateral to control abduction and rotation and the AP plane to control flexion.
ASHOK GAVASKAR: So Collinear clamp is also another great tool if you want to use it. I prefer them for certain spiral fractures and also some long oblique fractures. So you can go or get if you have access to a clamp, the advantages like it can be used through a very small incision. It can let us like sometimes you are going to use a pointed plan or even a serrated bone plan, and sometimes it can be difficult to place them through a small incision where the collinear clamp can be placed very effectively through a small incision.
ASHOK GAVASKAR: So it does well as well. It does, it does work as well. So to me, the most difficult fractures to reduce the sub-troch are the plantar's fractures because it's difficult to clamp or wire them so it often requires open reduction in my hands. Joysticks are is one tool that I try to use but sometimes if I'm not successful, I will have a very low threshold to go again, open it, clamp it on both sides, reduce and then go again with my reduction by nailing so transverse fractures can be really difficult to reduce so you should not hesitate to resort to an open reduction.
ASHOK GAVASKAR: So if you do all the reduction tips and tricks like this is an elderly female, the A3 kind of fracture, as you can see, there are kind of a transparent fracture and also fracture in the coronal plane that goes high up into the entry point of the nail. And there is a tremendous amount of osteoporosis as well. So if you look at the AP and the lateral Player C arm majors, you also have medial translation in the AB plate and a flexed proximal femur in the lateral plate.
ASHOK GAVASKAR: So push pull techniques again, like are a great tool like you can use a ball spike pusher or different kind of pushes can be used and you can also use a bone wheel, kind of like just this translator deformities so that you can reduce and then nail them successfully. So here, if you look at one pusher controls the medial translation and the other one in the different plane controls the reduction of the sagittal plane.
ASHOK GAVASKAR: So once you've got your reduction, you can go again. This can be done using very minimal small incisions. So you can go together and then nail them anatomically and they will do well. Another very similar case with a comminuted reverse oblique pattern of broken lateral wall, again, an elderly patient and osteoporotic with the low velocity fall. Again, in these cases, we prefer to use high profile nails, as we saw in the last case as well.
ASHOK GAVASKAR: But in elderly patients, we tend to use epicondyle nails most of the time. So again, if you look at it, you have a translator deformity in the coronel plane, a bone hook works great as well. It's a very simple instrument that's available to everybody. You can go again, use a bone hook to correct it and then simultaneously if required, you can use a ball spike pusher as well in the sagittal plane and then control your reductions.
ASHOK GAVASKAR: Go head, start your entry and then we send consent regularly and then go ahead and put in your nail and you can see it heals well at six weeks pretty much. So there's, so these are the kind of reduction techniques you guys can think of when you want to minimally invasive, minimally reduce, reduce your sub-troch fracture with minimally invasive techniques. So these are different kinds of tools, but you cannot say like one tool works for all fractures.
ASHOK GAVASKAR: Most often you may have to rely on a combination of tools. So but if you can read and plan your fracture carefully and spend some time on it on table, most of these fractures can be reduced without a formal reduction, open reduction, supine on a fracture or a regular table. So if you look at this case, like a 63-year-old male who had a low velocity fall, obese, you can see the spiral fracture pattern.
ASHOK GAVASKAR: This is how it looks on the fracture table. Looks pretty good reduction on both planes but once you start nailing it, it kind of drifts inwards, this is because the entry point is wrong here, as you can see. So even if you have a good reduction, unless you have your entry point right, and you use a nail of an appropriate proximal angle, you can still drift the fracture into varus.
ASHOK GAVASKAR: So reduction is one thing and then nailing is the other. So you have to kind of make this go angled and you have to understand that if your nailing technique is not proper, you can still end up with a mal-reduced fracture. So what are the hurdles that kind of like doesn't allow you to get a good entry for nailing a sub-troch fracture? So if you look at this case, you can see the iliac flare coming up and not allowing the surgeon to get a straight shot at the femur.
ASHOK GAVASKAR: So this can happen in a lot of muscular patients and also obese patients, especially if you are operating them supine. So you can have iliac impingement, which might not allow you to get a straight shot at the femur. We're using an ideal entry point, which will be a few millimeters medial to the tip of the greater trochanter. The gluteal muscles also doesn't help your cause.
ASHOK GAVASKAR: So especially in very muscular patients and obese patients, they can also push you a guidewire more and more laterally and not allowing you to get a straight shot at your femur. So the thing is like this iliac impingement and the influence of the gluteal musculature is real and you have to overcome this. One way is to start as high as possible, so that the skin entry has to be as high as possible,
ASHOK GAVASKAR: so that you get your entry point absolutely in line with your femoral shaft. So sometimes, especially in very obese patients, your entry point skin can be really, really high. So before you commit an incision, make sure you get your entry point trajectory, right and then start extending your incision from proximal to distal. Sometimes this entry point can be as high as the iliac at the ASIS.
ASHOK GAVASKAR: So what are the tips to get a good entry? So if you are doing it in supine, make sure you have some kind of inflection so that the entry point is translated posteriorly. Where you are iliac crest, the flare will not interfere and make it difficult. So have some kind of inflection. If you do it on a fracture table or a regular table, have some kind of inflection, which will definitely help a lot.
ASHOK GAVASKAR: And another way is to do it, in lateral position, as I told you. So as I said earlier, a larger position definitely gives you a great access to the entry point without any kind of hurdle. It's absolutely easy, but it can mix, it can make a lot of other things difficult if you are not really well versed how to do it. So, but this is one way of doing it as well. So the second thing is like,
ASHOK GAVASKAR: we appreciate the importance of medial reaming when you nail proximal femoral fractures especially the osteoporotic ones. So if you look at this lateral image, for example, the trajectory is not appropriate, though not accurate. I would probably prefer to go a little bit more arial, but it is not really bad. If this is a sharp fracture, this will work very well.
ASHOK GAVASKAR: But if you look at where the nail goes in, the fracture that still dips into varus, that is because when you start reaming your fracture even they were entry point, maybe right especially if you are dealing with an osteoporotic bone, you will reamer will tend to cut out the more weaker lateral bone unless you control it. So that will make your nail or the reamer fall in to the lateral side
ASHOK GAVASKAR: and then that will create a mismatch between the nail angle and the proximal femoral angle, which will again predispose the fracture to drift into varus. So again, reaming your bone on the medial side and preserving the lateral bone is important when you ream a fracture so that you can nail, nail them successfully. So once you have corrected that, once you have, there are a lot of ways to do it.
ASHOK GAVASKAR: Angle plate, we practice with artery clamps. A lot of things have been described, but none of them work reliably that you can use it for all fractures. So it depends, so make sure you have your sleeve in. If you are finding the medial cortical bone, you can also use the wrong word to rebuild the medial cortical bone so that you can ream that out before you can pass your nail in.
ASHOK GAVASKAR: So make sure you preserve the lateral bone and do not allow your reamer to fall into the lateral side, removing or covering out the entire lateral bone. So if it does happen, your fracture make sure plasmid will definitely drift into varus and you have to avoid that. So and this is one way of getting a perfect nail entry and a perfect nail trajectory and I like this a lot.
ASHOK GAVASKAR: That is like reaming and creating an entry point through the fracture site in a sub-troch fracture. So this is how we do it, and we do it in quite a few fractures, like we started doing it in lateral position for our revision cases, like where we open it up and then create an entry point, a fresh entry point, because this practice has been already made so I want to avoid that entry point
ASHOK GAVASKAR: so and to go more medially, which can be really difficult if I come from proximal. So we started using this in some revision fractures like there since when you go over through the fracture site, you are actually going from lateral to medial compared to when you come from proximal where you are always struggling to go to the medial side. So this is a very easy way of doing it and now we do it in supine position as well,
ASHOK GAVASKAR: so it is quite easy, you don't need a reduced fracture to do it. So you make use of the fracture displacement, go through the fracture side, pass your guide freely, it will zip through the biodiformis fossa or motor medially. So your entry point is already determined and you are not going to go wrong here. And once you have got your entry point from on arthro-osteotomy and then use your channel reamer and once you have got it, you can reduce your fracture and then create a proximal incision and put your guidewire in so you can do it in supine as well.
ASHOK GAVASKAR: So we use it, as I said, in two indications like atypical fractures and revisions but now we do it in fresh practice as well, where we resort to open, it saves you a lot of time and we published this recently as well, in Injury and these are some of the advantage, as you can see in these images when you go from distal I, I can kind of sort it wherever I want
ASHOK GAVASKAR: but when you are coming from proximal, even when you reduce a fracture and wall it anatomically, there are still hurdles like the iliac flare impinging on your drill. So you will still have hurdles in getting your entry point right and not just the entry point, your trajectory has to be right as well. A lot of times in proximal femur fractures like you will have a medial comminution and you will tend to fall onto the medial side.
ASHOK GAVASKAR: So when you do it from a retrograde manner, you go from lateral to medial, from distal to proximal so it's really easy to control that and so this is how we do it in atypical fracture. So in atypical fractures, a couple of things are very important. You need to have a well medialised entry point. And two, there is a lot of endosteal remodeling on the lateral side and unless you remove it, your reamer will kind of tend to fall medially because that is a reamed
ASHOK GAVASKAR: medial bone and then remove all the medial bone, which will, again, make the fracture go into varus. So as you can see in this fracture, like here in the medial cavity was completely sealed on both sides. So again, like we open it up, create a cavity, and then take a retrograde entry point and which sort of gets us into the biodiformis fossa and then we can go again and nail this anatomically.
ASHOK GAVASKAR: Since the nail is in the middle of the axial cavity, you will not create a mild reduction. So another case of an atypical fracture here, very similar principles as you can see here, we are like in spite of adequate endosteal reaming, we still had a problem. So a lateral plate was used to control that and then nail it successfully, which goes on to heal. So to summarize, if you want to reduce and nail a subtrochanteric fracture successfully, three things are important.
ASHOK GAVASKAR: One, you need to achieve an anatomical fracture reduction or a functional fracture reduction whereby I mean you restore length, alignment and rotation and adequate bony contact. This has to be done biologically. Doesn't mean that this has to be done closed or using minimal access. You can also do open reduction and we have to be biological.
ASHOK GAVASKAR: So ultimately, as I said in the first slide, mechanics are the key, you need to respect biology, but mechanics are the priority. Second, you need to have a good nail entry. To have a good nail entry, you need to have a good fracture reduction. Often the appropriate nail entry for sub-troch fracture would be slightly more medial to the tip of the troch. It's somewhere around 3 to 5 millimeter medial to the tip of the troch and that is where you need to enter.
ASHOK GAVASKAR: And you preferably use an angle, you use a nail that does not have a huge medial lateral angle proximally. Most of the current generation may allow around 4 to 5 degree angle to allow ease of access and you can get them well medial to the tip of the troch. You don't have to enter the tip of the troch where you will most often end up mal reduced. Third, once you've got your fracture reduction entry right, you have to make sure you nail it appropriate using appropriate techniques so that you avoid loss of reduction.
ASHOK GAVASKAR: So to avoid loss of reduction, as I said, nail entry is important. You need to remove the medial bone and if you are dealing with atypical fractures, you have to be careful about the endosteal bleaching and you need to remove that as well. So unless you are careful about the nailing process, you can mal-reduce a fracture which has been previously well reduced during the nailing process.
ASHOK GAVASKAR: Thank you.
HITESH GOPALAN: Thank you, Sunil, for that brilliant talk of yours, and you've covered almost everything about technical tips. And I remember the good old days when we started doing the gamma nail and the cyrus nail and how difficult it was to get people convinced that the intramedullary nailing is going to be the future.
HITESH GOPALAN: Ah Sunil, a couple of questions. Now, not one is regarding, I guess. Yeah, one is regarding the technical tip where you showed that particular paper from South Korea, where they've used an artery forceps ANOK GAVASKAR [I lost you mate]. Sunil, can you hear me? Yeah, yeah I can hear you, now. Yeah so the question is, you showed a paper where they've used an artery forceps to do that internal rotation moment right?
HITESH GOPALAN: Do you think a Hommand spike would be a better thing, do you think artery forceps could do that interrogation, because it's very strong, muscular. Right Yes. So do you think a Hommand spike would be a better choice?
ASHOK GAVASKAR: Yeah possible, you can use it. OK you can use it.
ASHOK GAVASKAR: Probably something with the day of use artery use is a plantar plan. I use a car called with the long handle most of the times and I tend to start off like, use it. as posteriosly as possible. Start so.
ASHOK GAVASKAR: So I'm then let go again. As I said, like as you said, a Hommand shouldn't be a bad choice any it's just an instrument like anything that goes under the vastus to make use of the vastus brutalial attachment relationship to bring in internal rotation.
HITESH GOPALAN: Thank you, Sunil, for that. And the other question is, see, what has happened in last 10 years is not subtracting.
HITESH GOPALAN: If you talk about intra-trochantric as well, everyone is going towards this particular [INAUDIBLE] Right? Everyone is obsessed about putting AP, F and and A2. OK? And do you think there are significant complications with AP and F and A2 like a femoral head perforation and androgenic lateral perforation? And do you think a AP and F and A2 has more complications compared to a regular PFM? What does the AO dictate?
ASHOK GAVASKAR: Yeah so I think like a few things. Like if you mean by a regular BFM, if you mean the two screws that AO sometime introduced, I think that is probably, in my opinion, like we never had that AO device in India actually. Like we had only the Indigenous made a two screw fence which came in eight and six, seven screws. But if you look at the AOP sets like that's 11, the weight bearing is actually 11 and we never had it there actually.
ASHOK GAVASKAR: But so when you have an eight, nine, six, seven, six, seven screw is an anti rotation screw where the one they screw is the weight bearing screw. I thought that was not a great construct to deal with the geriatrics sub drug facts are a drug factor. So so I'm not when you say a regular patient that is not my go to Device. But I think gamma OK or any screw based device, I think when the blade came, it was thought that would give you superior outcomes compared to a screw.
ASHOK GAVASKAR: But I really don't think so because like we used it for five years continuous and we published our results in 2013 I think, we reported a 30% complication rate over the BFD and A2. So I and if you look at subsequent literature after that and there are quite a few papers in Brazil, ones that report that the number of complications are probably more with blades and also the blades
ASHOK GAVASKAR: do not give you superior outcomes even in osteoporotic fractures. I don't think they are better than a screw, so I'm quite convinced with regards to that. So right now, like the thing is like I use blades, I don't use the PFNA, but I use that for the, the more recent one. But, but I, but I agree with you. But the PFNA, I think there are certain design and design advantages compared to APF.
ASHOK GAVASKAR: Definitely but right now, like my go to device would still be a screw based implant for the osteoporotic sub-troch fracture. I use a PFNA or BFNA in select situations.
HITESH GOPALAN: Now what is the difference between a DFNA and a trochanter fixation like the DFN? What are the design difference?
ASHOK GAVASKAR: Yeah so if you look at the lateral profile of the BFNA, it's much lower.
ASHOK GAVASKAR: So that it is, it allows you to input it inside easier and also lessens the possibility that you might break the lateral wall once and then like there is a possibility to compress and then you hold your fixation. That was not possible, I think if you look at the concept with the integrated lag screws from Smith & Nephew, if you like, the concept is we always used to believe that these fractures should be allowed to slide and collapsed during the process of fracture healing.
ASHOK GAVASKAR: That is how we have been taught. But I think there is good enough evidence right now that you can compress these fractures on table under vision in a very controlled manner, rather than relying on dynamic collapse that happens during fracture healing, which may not be under your control at all. So once you have done that, got your fractures fixed in a manner that you want, you stop everything, don't allow any more sliding.
ASHOK GAVASKAR: So those kind of concepts have shown initial success in initial good success as well. So right now the BFNA design allows you to do that. So where you can kind of completely lock it so that you don't allow your fracture to collapse, or if you want to allow it to collapse, still you can do it. So you have the option of doing it both, and that is the current kind of design concepts most people believe in.
ASHOK GAVASKAR: So I think that has benefits. And you might, you, you might remember we published our results as well like you like where we compared both and we and not in terms of major complications. But there were certain advantages with the integrated lags compared to a blade.
HITESH GOPALAN: Thank you, Sunil, for that. Just one last question before we wind up the session.
HITESH GOPALAN: Are there situations where you don't want to use an intermedullary nail, for example, is there a contraindication and where you would prefer a locking plate, OK a proximal femoral locking plate?
ASHOK GAVASKAR: Yeah so for me. Proximal, if you ask me. I use a plate, yes, I use a plate.
ASHOK GAVASKAR: The most common indication for me to plate a proximal femoral fracture will come in a revision situation where I use a blade plate, sometimes alone. or some times I will use an anteriol plate, but in a primary situation. I very rarely use blade plates, proximal femoral plates yes I have used it but very few times. My indication for using a plate in a primary situation is like when I have a lateral wall that is completely floating where it has no kind of relationship with the proximal fragment.
ASHOK GAVASKAR: So in this case, it's like my options are; go get reduced the lateral wall to the proximal and the distal fragment and then go again with my stabilization. So in this scenario, there are a few instances where I have gone ahead with the proximal femoral lock plate because here, unless you reduce it, I don't plate my lateral wall in all fractures as some people do it.
ASHOK GAVASKAR: So there are some proponents who say whenever a lateral wall is fractured, they should plate that as well and there are some innovative designs where they have a nail and a plate going together as well. So but we don't do it that way. But I mean, whenever my lateral wall is completely floating, in those instances, I go or get dual open reduction and from there on
ASHOK GAVASKAR: it's either a proximal femoral plate or a nail with an additional lateral plate, a low profile one.
HITESH GOPALAN: Thank you, Sunil. Sunil, I think that's all the questions that we have for this session. Fantastic lecture and I'm sure this lecture is going to benefit a lot of people all over the world.
ASHOK GAVASKAR: Thank you so much mate. Thank you so much. Thanks for the invitation.
Segment:0 .
HITESH GOPALAN: Good evening everybody, and welcome all of you to this live program of orthopaedic principles. Today, our guest of honor is Dr. Ashok Gavaskar from Chennai, India. Dr. Ashok Sunil Gavaskar is currently the clinical leader of orthopedics and heads joint reconstruction trauma services at the Rela Institute and Medical Center in Chennai, India. He is a distinguished member of the AO Trauma Technical Commission as part of the Asia-Pacific expert group.
HITESH GOPALAN: He's an honorable member of the International Advisory Board for General American Academy of Orthopedic surgeons. He also serves as an associate editor for the Indian Journal of Orthopedics and the European Journal of Orthopedic Surgery and Traumatology. So today, it's my great honor to introduce you to Dr. Ashok Gavaskar from Chennai, India. Over to you Ashok.
ASHOK GAVASKAR: Thank you. Thank you Hitesh for the introduction and thanks for the opportunity to speak on your platform as well. So can I go again?
HITESH GOPALAN: Yes, please. Yeah OK.
ASHOK GAVASKAR: So I will be speaking to you about the
ASHOK GAVASKAR: Nailing in trochanter fractures. I have just titled it as reduction and fixation go
ASHOK GAVASKAR: hand in hand because that truly does. And I would focus predominantly on select problems and surgical tips and techniques that you can use to kind of nail successfully. All kinds of subtrochanteric fractures that you might encounter in your practice. So these are my disclosures. None of them are probably relevant to this talk.
ASHOK GAVASKAR: So the learning objectives for this webinar would be to learn more about nailing of subtrochanteric fractures, focusing on how to understand the deforming forces that act to the proximal femur that you might have to handle when you try to nail this fractures. We will review the common displacement patterns in proximal femoral fractures in general and how they influence your surgical technique. We will also understand the common problems that you might face during nailing of subtrochanteric fractures and how to overcome them.
ASHOK GAVASKAR: I'll tell you how to perform various, minimally invasive and open reduction techniques that are often required when you deal with these fractures and also select tips and tricks when it comes to nailing of this problem fractures. So first of all, the question is like, when there are so many difficulties, why choose nailing of a subtrochanteric fracture? Why should we do it?
ASHOK GAVASKAR: Why not do a different option? The first thing is the biomechanical advantage that a nail will give you. We all know that with regards to the lever arm and the forces acting upon the implant and also the fracture, the nail gives you a favorable loading pattern because it is centered along the medullary cavity. And so when you have a medial defect or a lateral wall failure, a nail being in an medullary location gives you an enormous advantage with regards to resisting the forces across the fracture.
ASHOK GAVASKAR: Nail also tends to be a more kind of a load sharing implant so it tends to load the fracture if you allow the weight bearing and also doing dynamic forces that act along the hip during range of motion. So being a load sharing implant definitely helps with regards to loading patterns across the fracture and also in healing and also allows the patient to be active and use this hip joint during the course of fracture healing.
ASHOK GAVASKAR: And then, when you choose a nail, it also helps you to do it in a minimally invasive manner though it may not be always possible, especially in sub-troch fractures. This is very much a realistic option in select fractures at least where you can do a closed reduction or even a minimally invasive percutaneous reduction so that you don't disturb the biology of the fracture too much.
ASHOK GAVASKAR: What is nailing a sub-troch fracture really easy? Definitely, no. Especially when it comes to an A3 fracture, nailing it is definitely not easy. And if you don't nail it to well, you are bound to fail most often and failures can result in a lot of problems, especially loss of bone, that might make future reconstructions definitely more difficult.
ASHOK GAVASKAR: And if you look at the literature, the amount of malunion, especially like, look at the non-union things like they will definitely fail. Even if you succeed, the amount of varus malunion you get in the proximal femur is tremendously high, around 33% and these patients never do normal. They might still have a hip that is functioning, but they do have a lot of limitations. And even in this series, patients who got to open reduction did better in terms of achieving a normal proximal femoral anatomy that you need to keep in mind as well.
ASHOK GAVASKAR: So how to prevent failures when you nail a sub-troch fracture. You have to remember mechanics are the key, though biology is important. When you think of treating a sub troch fracture, you need to restore mechanics, that is paramount. You have to remember union is not the only goal. You need to make the proximal femur look like a proximal femur
ASHOK GAVASKAR: so that it works seamlessly as it used to before the injury. Remember, reduction is paramount, otherwise most sub-trochs will fail whether you nail or flame, you need to restore length, alignment and rotation and make sure you do not leave your sub-troch fracture distracted, this is bound to fail as well. So if you want to prevent failures, you need to restore the proximal femoral mechanics.
ASHOK GAVASKAR: So why are nail malalignments so common when you nail a sub-troch fraction, why does this happen? Most often it happens because we end up adding a wrong entry point. This happens in turn because you have not got a good reduction. So when you nail a sub-troch fracture, the main difficulty is is this the failure to control the small proximal fragment? That is what predisposes to all our problems. You can get a mild reduction, which in turn will predispose you to the wrong entry point and then subsequent further malalignments.
ASHOK GAVASKAR: So if you look at general, if you look at the main points, why nailing a sub-troch fracture is difficult, one is the deforming forces, you know that the proximal femoral fragment in this fractures will be flexed abductor and externally rotated, and this will remain so even when you put the patient on traction most of the time. So you need to go in there, get this fracture fragment reduced before you can start your nailing procedure,
ASHOK GAVASKAR: otherwise, more often than not, you will end up with problems because your nail will not reduce the fracture, which is mal-reduced. So without reduction you do not get a good nail entry. So if you want to reverse this pattern, it will never, ever work, so it's always reduction first and reduction can be very, very difficult on this short fragment. Second, as I said, is that the proximal fragment, which is bound to tremendous amount of deforming forces, is also short most of the times.
ASHOK GAVASKAR: And when it is short, the more difficult it makes for us to achieve a reduction. When you have a fracture, the subtrochantric region that is slightly lower, it tends to be more like a proximal femoral shaft fracture and then the reduction is much more easier but when you go higher, it is much, much more difficult because all these muscular forces, the abductors, external rotators and the flexors tend to be concentrated on that small fragment, making the reduction extremely, extremely difficult because it is multi planar.
ASHOK GAVASKAR: So, and as I said, this fracture will not reduce the fracture and you have to rely on different means. And will my nail reduce a fracture? No, because the proximal fragment is too short and sometimes the posterior segment of the proximal fragment is often much shorter, so you will not have an inflammatory reduction tool available and you will need to rely on some of these techniques.
ASHOK GAVASKAR: And a third problem is nailing processes as such can malalign even a well reduced fracture. So if you look at this example, it appears to be well reduced in terms of reduction on the AP view, but your nail injury can actually malreduce it. This happens because of mismatch in the angle between the nail and the next sharp angle and when that happens you will predispose or shift the proximal fragment into varus, causing a mild reduction.
ASHOK GAVASKAR: So a lot of things can happen over nailing of the sub-troch fracture that has to be handled. And last thing is, like sometimes the anatomy itself might make it very difficult. That is the case with atypical fractures. If you look at this example, you can see that the proximal femur is not normal, you can see the medullar cavities closed and you can see a lot of endeostomy remodeling on that proximal femur
ASHOK GAVASKAR: and if you are going to nail this, this can be really, really difficult and often you can end up in mild reductions like this. For atypical fractures, nailing is a great choice, but can be really difficult unless you follow certain principles and tricks. Otherwise, these can be really tough on you and also on the patient. So we and from my preceding slides, you would have understood that with regards to successfully treating sub-troch fractures, it is all about reduction.
ASHOK GAVASKAR: Unless you get a reduction, you will not be successful, and even when you get a reduction, you still have to complete nailing without losing reduction, that is a different task by itself. So I'll just take you through different case examples focusing on reduction techniques predominantly.Of course, like my pressure to open a sub-troch fracture is very, very less but in spite of that, I think like a lot of times if you can spend some time, most of these fractures are amenable for minimally invasive reduction techniques that you can perform successfully.
ASHOK GAVASKAR: So I'll take you through various reduction options that are possible and also tell you some tips and tricks how to do it. So if you look at this case example, this guy is an elderly gentleman who had a low velocity fall and had a spiral sub-troch fracture that looks like this. So if you kind of put him on fracture table, we do this practice on fracture table most of the times, but I often do it without traction.
ASHOK GAVASKAR: So this is how he looks on traction and this looks to be reasonably acceptable on AP view. But is this really right to go ahead with the nailing? I don't think so, because if you look at the AP view carefully. If you look focused on the greater trochanter, you can see that the greater troch is definitely not appearing as a point. This indicates that the greater troch or the proximal fragment is still externally rotated and you do not have an ideal entry point.
ASHOK GAVASKAR: So you need to correct it so that you can get a more medial and correct entry point, and if you look at the lateral, it looks OK, sorry, it looks off. I'm not able to see it on the screen. The lateral looks off, so definitely on both views it is not ready to start your daily process. So what do you do? We can go ahead and do minimally invasive reduction technique to get your reduction right.
ASHOK GAVASKAR: So this is an interesting technique, a very simple one as well from Korea. These guys describe a simple surface technique where you can correct external rotation of the proximal fragment. So what these guys do is they use an artery clamp, go through the vastus, and then slide the artery clamp over the proximal femoral fragment anteriorly and then lever it into an internal rotation kind of thing.
ASHOK GAVASKAR: So what happens is like the artery clamp uses the muscle attachments under the lateral side to bring in internal rotation of the proximal fragment that is externally rotated. So this is a very easy technique to do and good thing is, is this does not interfere with your daily process, you can also do a k-wire or a shaft spin into the proximal fragment to control that
ASHOK GAVASKAR: but the problem is you have to really place them correctly. so that your nailing process goes on in there. But this happens on the surface so it doesn't interfere with the nailing process at all, and as you can see on the left, they mainly just from their own articles, you can see that once you have artery clamp is in place, you can see that the greater troch now appears in profile as a point and you can go slightly medial to the right entry point and start nailing this one.
ASHOK GAVASKAR: So this is a great precursor and I use it all the time and a lot of times this one helps me to control the flexion deformity as well, not just the external rotation. So sometimes this will be the one reduction tool that I will use in a sub-troch fracture. So this is a great tool to use actually, it takes no time and no fluoroscopy is required. So you've got your AP reduction right, but your arthro lateral still does not look good.
ASHOK GAVASKAR: So at this point therefore you can see the Arctic lamp lying over the proximal fragment, but here my flexion is not so corrected. So at this point, a lot of us will think like, can I go again and try to nail it along the axis of the proximal segment and then get it to the distal segment? I think you should resist because as you can see, the proximal segment posterior is extremely short and your nail will never work effectively as a joystick here.
ASHOK GAVASKAR: So what next? Our go to would be to use multiple clamps. You can use pointed clamps that you can place them in both lateral and AP plates and you can also use the serrated bone clamps as well and often you require a multiple of tools. Our go to tools would be the pointed clamps, the bone hooks and the ball spike pushers along with the artery clamp anteriorly.
ASHOK GAVASKAR: And most often with the combination of these tools, you will be able to kind of reduce your fracture, as we have shown here in one of our examples and then once that is done, you can go ahead and nail your fracture, which will go on to heal in an anatomical manner. So this is an example of some kind of surface reduction tool that you can use in a sub-troch fracture. So if you look at this guy again, for example, just to highlight the utility of the anterior artery clamp.
ASHOK GAVASKAR: 22 male with a high velocity injury, he's got kind of a low sub-troch, but with significant amounts of communition.
ASHOK GAVASKAR: And if you look at the c-arm images, this is how it looks under a little bit of traction. As you can see, the AP looks kind of OK, but it is still externally rotated, as you can see, by the lesser sub-troch profile and the lateral looks completely off. So again, the same technique, we go again and use an artery clamp, you can see that we are bringing the internal rotation into the proximal fragment now.
ASHOK GAVASKAR: And you can see on the lateral view also I'm getting my proximal fragment in line within the main distal shaft fragment. So once I've gone, once I've got that, I can go ahead and get my nail entry done under carefully, under fluoroscopy and gradually I can reduce this fracture absolutely closed and get my nail inside and that is how it looks like at the end of the procedure. So sometimes, as I said, this would be the only reduction tool that I would require to reduce a sub-troch fracture, which is quite easy.
ASHOK GAVASKAR: So what other clamps that you can use? You can use a lot of other clamps as well. So this was a 37 male, but that's kind of a trans-troch. entry fracture, as you can see, he's got a commination on the lateral side as well and this is not going to reduce interaction and without reducing this one, you will never get your nail entry right so if you look at this, this is what it looks like.
ASHOK GAVASKAR: If I'm going to kind of go there with this picture and start nailing it, there is a high possibility that I might go through the fracture and compromise or blow out the lateral wall. So these fractures require reduction and you can reduce them almost anatomically with the clamp so that you will get a right entry point and also preserve the lateral wall. So go again, a couple of pointed clamps on the lateral wall, hold them in place and then nail them,
ASHOK GAVASKAR: they do absolutely well. And in the young patients, this is the kind of nail that you will require. You don't require the high profile nails like the proximal femoral nails that you use in the elderly patients because like they will take up a lot of bone and can make the process much, much more difficult. So what you require in this practice, many patients, is the type of nails which have a much lower profile.
ASHOK GAVASKAR: So there's another male, a 44-year-old with a comminuted A3 type fracture. Again, as you can see, there you have a fracture on the lateral wall as well, which appears separate fragment. So again, if you look at it on the AP, it looks reasonable, but on the lateral plate, you have a mild reduction. Again, like here we go again for a small incision and then the sagittal plane goes there, reduce it plane anatomically and then go ahead and nail it , so you can use a different, different varieties of clamps.
ASHOK GAVASKAR: So depending on what kind of a fracture pattern we have. So what about wires and cables? They are great tool as well. In select sub-troch fractures, we use them in spiral sub-troch fractures and also some fractures which are long oblique tools, kind of like all them reduced when we nail our fractures. So they can be used as a biologically effective tool, You do not have to have concerns about it in terms of affecting the blood supply of the periosteum.
ASHOK GAVASKAR: Several experiments have shown them they are effective and they are biological as well. There are percutaneous tools as well, which you can use to pass them elegantly and hold your fracture reduced till you nail it. So this is one of the case, like the same one, the same case, which we have shown here, a single wire and then nailed effectively, which went on to heal uneventfully at three months.
ASHOK GAVASKAR: This was another case in an elderly male, the communuted sub troch and as you can see there, you can see a butterfly comminution on the medial side and all the typical deformities that you will encounter in a subtroch fracture and this is what it looks like. So we are probably like, I could have gone ahead without wiring this as well, because I don't think that fragment actually helps in kind of stabilizing it, but
ASHOK GAVASKAR: some so, again, the same technique you can see the arctic lambp coming in and then my entry and I felt my, my, my reamer was going into the medial side varsus that because that is a pathway of the least resistance, your nail kind of tends to go in medial side through the comminution. So I had to start up like wire this arms so that I can get my nail centered in the medular cavity and not getting the proximal fragment into varus.
ASHOK GAVASKAR: So just a single wire toward that butterfly fragment, which is part of both the approximate and the distal segment. So that is one problem. So once we have done that without your nail in place and then it looks pretty well reduced in both planes. So another case. Obese patient with a BMI of 37, a similar spiral comminution then this was considering his obesity, we did it in lateral position. Lateral position does make certain things easier, especially the entry and certain amount of reduction as well
ASHOK GAVASKAR: but it makes a lot of other things difficult too like access to fluoroscopy and sometimes like even the entire nailing process can be a little bit difficult to do So like, I prefer to do them in supine position but lateral position can be useful in patients, especially one obese, and I also use them in revisions as well. So in this case, like we used two wires, one was to reduce the lateral wall to the proximal fragment to, in order to contain the nail.
ASHOK GAVASKAR: So if you have a lateral wall fracture and if you want to keep that, and if you want to use a nail, you have to make sure the nail is contained. So if you have a lateral wall fracture that is undisplaced, attached to soft tissues heal well, then you do not have to worry about it as long as your nail is contained. But if you have a lateral wall that is kind of floating, going, drifting posteriorly or migrating superior, then those Lateral walls should be put back in place and stabilize so that your nail will be contained in the proximal segment and then other wire to hold and reduce the main fracture line.
ASHOK GAVASKAR: And then it goes on to be fixed, fixed and heal well at 3 weeks, three months. So what about other reduction techniques? Joysticks are a great tool as well, I use them quite, quite a lot, especially in fractures that are short, oblique and transverse where I can't use clamps very effectively. So if you are trying to reduce this fracture in a closed or a minimally invasive manner, joysticks are a great way to do it.
ASHOK GAVASKAR: So you can use joysticks in both planes in either from lateral to medial to control abduction and also rotation and also in the flexion extension deformity can be controlled by passing a joystick in the anteroposterior plane. So here if you can look at it, there's a joystick on the medial lateral plane to control abduction, and once if you are pushing them carefully, much anteriorly, you can go again and the nailing can be done without any hindrance.
ASHOK GAVASKAR: Here are a few more reduction techniques that have been used to control and center the nail in the proximal fragment with the posterior blocking pin as well. And once done, this can go on to heal without any problems. So another case to illustrate an anteroposterior joystick, if you can look at this again, the proximal segment in the fracture line is pretty much a short oblique or a transverse bit kind of a comminution in the medial side.
ASHOK GAVASKAR: So this is what it looks like on the APM lateral view. So you can see the AP looks pretty much aligned, but the lateral you can see that is a flexion deformity. So here I don't need a joystick from the medial lateral plane because that looks all right. But the flexion extension deformity, if you want to correct it, joystick is a great tool. So what I typically do is put a joystick medially into the lesser troch region, which has got great hold and you can do it in a safe manner by using a sleeve.
ASHOK GAVASKAR: And once it is in place, you can kind of use the joystick to correct the flexion deformity and go ahead with your nailing because this wire is in the region of the lesser troch, well outside the intramedullary cavity. So it doesn't come into the picture when you start nailing your fracture. So this is what it looks like. You can see the location of the joystick over there on the medial side.
ASHOK GAVASKAR: So once you connected to the deformity, you can go again, get your nail and this is what it looks like. So joystick placement, if you want to use them, choose your fracture. It works well in antroverse and chart oblique fractures and depending on the deforming force, you may choose to use one or two joysticks medial-lateral to control abduction and rotation and the AP plane to control flexion.
ASHOK GAVASKAR: So Collinear clamp is also another great tool if you want to use it. I prefer them for certain spiral fractures and also some long oblique fractures. So you can go or get if you have access to a clamp, the advantages like it can be used through a very small incision. It can let us like sometimes you are going to use a pointed plan or even a serrated bone plan, and sometimes it can be difficult to place them through a small incision where the collinear clamp can be placed very effectively through a small incision.
ASHOK GAVASKAR: So it does well as well. It does, it does work as well. So to me, the most difficult fractures to reduce the sub-troch are the plantar's fractures because it's difficult to clamp or wire them so it often requires open reduction in my hands. Joysticks are is one tool that I try to use but sometimes if I'm not successful, I will have a very low threshold to go again, open it, clamp it on both sides, reduce and then go again with my reduction by nailing so transverse fractures can be really difficult to reduce so you should not hesitate to resort to an open reduction.
ASHOK GAVASKAR: So if you do all the reduction tips and tricks like this is an elderly female, the A3 kind of fracture, as you can see, there are kind of a transparent fracture and also fracture in the coronal plane that goes high up into the entry point of the nail. And there is a tremendous amount of osteoporosis as well. So if you look at the AP and the lateral Player C arm majors, you also have medial translation in the AB plate and a flexed proximal femur in the lateral plate.
ASHOK GAVASKAR: So push pull techniques again, like are a great tool like you can use a ball spike pusher or different kind of pushes can be used and you can also use a bone wheel, kind of like just this translator deformities so that you can reduce and then nail them successfully. So here, if you look at one pusher controls the medial translation and the other one in the different plane controls the reduction of the sagittal plane.
ASHOK GAVASKAR: So once you've got your reduction, you can go again. This can be done using very minimal small incisions. So you can go together and then nail them anatomically and they will do well. Another very similar case with a comminuted reverse oblique pattern of broken lateral wall, again, an elderly patient and osteoporotic with the low velocity fall. Again, in these cases, we prefer to use high profile nails, as we saw in the last case as well.
ASHOK GAVASKAR: But in elderly patients, we tend to use epicondyle nails most of the time. So again, if you look at it, you have a translator deformity in the coronel plane, a bone hook works great as well. It's a very simple instrument that's available to everybody. You can go again, use a bone hook to correct it and then simultaneously if required, you can use a ball spike pusher as well in the sagittal plane and then control your reductions.
ASHOK GAVASKAR: Go head, start your entry and then we send consent regularly and then go ahead and put in your nail and you can see it heals well at six weeks pretty much. So there's, so these are the kind of reduction techniques you guys can think of when you want to minimally invasive, minimally reduce, reduce your sub-troch fracture with minimally invasive techniques. So these are different kinds of tools, but you cannot say like one tool works for all fractures.
ASHOK GAVASKAR: Most often you may have to rely on a combination of tools. So but if you can read and plan your fracture carefully and spend some time on it on table, most of these fractures can be reduced without a formal reduction, open reduction, supine on a fracture or a regular table. So if you look at this case, like a 63-year-old male who had a low velocity fall, obese, you can see the spiral fracture pattern.
ASHOK GAVASKAR: This is how it looks on the fracture table. Looks pretty good reduction on both planes but once you start nailing it, it kind of drifts inwards, this is because the entry point is wrong here, as you can see. So even if you have a good reduction, unless you have your entry point right, and you use a nail of an appropriate proximal angle, you can still drift the fracture into varus.
ASHOK GAVASKAR: So reduction is one thing and then nailing is the other. So you have to kind of make this go angled and you have to understand that if your nailing technique is not proper, you can still end up with a mal-reduced fracture. So what are the hurdles that kind of like doesn't allow you to get a good entry for nailing a sub-troch fracture? So if you look at this case, you can see the iliac flare coming up and not allowing the surgeon to get a straight shot at the femur.
ASHOK GAVASKAR: So this can happen in a lot of muscular patients and also obese patients, especially if you are operating them supine. So you can have iliac impingement, which might not allow you to get a straight shot at the femur. We're using an ideal entry point, which will be a few millimeters medial to the tip of the greater trochanter. The gluteal muscles also doesn't help your cause.
ASHOK GAVASKAR: So especially in very muscular patients and obese patients, they can also push you a guidewire more and more laterally and not allowing you to get a straight shot at your femur. So the thing is like this iliac impingement and the influence of the gluteal musculature is real and you have to overcome this. One way is to start as high as possible, so that the skin entry has to be as high as possible,
ASHOK GAVASKAR: so that you get your entry point absolutely in line with your femoral shaft. So sometimes, especially in very obese patients, your entry point skin can be really, really high. So before you commit an incision, make sure you get your entry point trajectory, right and then start extending your incision from proximal to distal. Sometimes this entry point can be as high as the iliac at the ASIS.
ASHOK GAVASKAR: So what are the tips to get a good entry? So if you are doing it in supine, make sure you have some kind of inflection so that the entry point is translated posteriorly. Where you are iliac crest, the flare will not interfere and make it difficult. So have some kind of inflection. If you do it on a fracture table or a regular table, have some kind of inflection, which will definitely help a lot.
ASHOK GAVASKAR: And another way is to do it, in lateral position, as I told you. So as I said earlier, a larger position definitely gives you a great access to the entry point without any kind of hurdle. It's absolutely easy, but it can mix, it can make a lot of other things difficult if you are not really well versed how to do it. So, but this is one way of doing it as well. So the second thing is like,
ASHOK GAVASKAR: we appreciate the importance of medial reaming when you nail proximal femoral fractures especially the osteoporotic ones. So if you look at this lateral image, for example, the trajectory is not appropriate, though not accurate. I would probably prefer to go a little bit more arial, but it is not really bad. If this is a sharp fracture, this will work very well.
ASHOK GAVASKAR: But if you look at where the nail goes in, the fracture that still dips into varus, that is because when you start reaming your fracture even they were entry point, maybe right especially if you are dealing with an osteoporotic bone, you will reamer will tend to cut out the more weaker lateral bone unless you control it. So that will make your nail or the reamer fall in to the lateral side
ASHOK GAVASKAR: and then that will create a mismatch between the nail angle and the proximal femoral angle, which will again predispose the fracture to drift into varus. So again, reaming your bone on the medial side and preserving the lateral bone is important when you ream a fracture so that you can nail, nail them successfully. So once you have corrected that, once you have, there are a lot of ways to do it.
ASHOK GAVASKAR: Angle plate, we practice with artery clamps. A lot of things have been described, but none of them work reliably that you can use it for all fractures. So it depends, so make sure you have your sleeve in. If you are finding the medial cortical bone, you can also use the wrong word to rebuild the medial cortical bone so that you can ream that out before you can pass your nail in.
ASHOK GAVASKAR: So make sure you preserve the lateral bone and do not allow your reamer to fall into the lateral side, removing or covering out the entire lateral bone. So if it does happen, your fracture make sure plasmid will definitely drift into varus and you have to avoid that. So and this is one way of getting a perfect nail entry and a perfect nail trajectory and I like this a lot.
ASHOK GAVASKAR: That is like reaming and creating an entry point through the fracture site in a sub-troch fracture. So this is how we do it, and we do it in quite a few fractures, like we started doing it in lateral position for our revision cases, like where we open it up and then create an entry point, a fresh entry point, because this practice has been already made so I want to avoid that entry point
ASHOK GAVASKAR: so and to go more medially, which can be really difficult if I come from proximal. So we started using this in some revision fractures like there since when you go over through the fracture site, you are actually going from lateral to medial compared to when you come from proximal where you are always struggling to go to the medial side. So this is a very easy way of doing it and now we do it in supine position as well,
ASHOK GAVASKAR: so it is quite easy, you don't need a reduced fracture to do it. So you make use of the fracture displacement, go through the fracture side, pass your guide freely, it will zip through the biodiformis fossa or motor medially. So your entry point is already determined and you are not going to go wrong here. And once you have got your entry point from on arthro-osteotomy and then use your channel reamer and once you have got it, you can reduce your fracture and then create a proximal incision and put your guidewire in so you can do it in supine as well.
ASHOK GAVASKAR: So we use it, as I said, in two indications like atypical fractures and revisions but now we do it in fresh practice as well, where we resort to open, it saves you a lot of time and we published this recently as well, in Injury and these are some of the advantage, as you can see in these images when you go from distal I, I can kind of sort it wherever I want
ASHOK GAVASKAR: but when you are coming from proximal, even when you reduce a fracture and wall it anatomically, there are still hurdles like the iliac flare impinging on your drill. So you will still have hurdles in getting your entry point right and not just the entry point, your trajectory has to be right as well. A lot of times in proximal femur fractures like you will have a medial comminution and you will tend to fall onto the medial side.
ASHOK GAVASKAR: So when you do it from a retrograde manner, you go from lateral to medial, from distal to proximal so it's really easy to control that and so this is how we do it in atypical fracture. So in atypical fractures, a couple of things are very important. You need to have a well medialised entry point. And two, there is a lot of endosteal remodeling on the lateral side and unless you remove it, your reamer will kind of tend to fall medially because that is a reamed
ASHOK GAVASKAR: medial bone and then remove all the medial bone, which will, again, make the fracture go into varus. So as you can see in this fracture, like here in the medial cavity was completely sealed on both sides. So again, like we open it up, create a cavity, and then take a retrograde entry point and which sort of gets us into the biodiformis fossa and then we can go again and nail this anatomically.
ASHOK GAVASKAR: Since the nail is in the middle of the axial cavity, you will not create a mild reduction. So another case of an atypical fracture here, very similar principles as you can see here, we are like in spite of adequate endosteal reaming, we still had a problem. So a lateral plate was used to control that and then nail it successfully, which goes on to heal. So to summarize, if you want to reduce and nail a subtrochanteric fracture successfully, three things are important.
ASHOK GAVASKAR: One, you need to achieve an anatomical fracture reduction or a functional fracture reduction whereby I mean you restore length, alignment and rotation and adequate bony contact. This has to be done biologically. Doesn't mean that this has to be done closed or using minimal access. You can also do open reduction and we have to be biological.
ASHOK GAVASKAR: So ultimately, as I said in the first slide, mechanics are the key, you need to respect biology, but mechanics are the priority. Second, you need to have a good nail entry. To have a good nail entry, you need to have a good fracture reduction. Often the appropriate nail entry for sub-troch fracture would be slightly more medial to the tip of the troch. It's somewhere around 3 to 5 millimeter medial to the tip of the troch and that is where you need to enter.
ASHOK GAVASKAR: And you preferably use an angle, you use a nail that does not have a huge medial lateral angle proximally. Most of the current generation may allow around 4 to 5 degree angle to allow ease of access and you can get them well medial to the tip of the troch. You don't have to enter the tip of the troch where you will most often end up mal reduced. Third, once you've got your fracture reduction entry right, you have to make sure you nail it appropriate using appropriate techniques so that you avoid loss of reduction.
ASHOK GAVASKAR: So to avoid loss of reduction, as I said, nail entry is important. You need to remove the medial bone and if you are dealing with atypical fractures, you have to be careful about the endosteal bleaching and you need to remove that as well. So unless you are careful about the nailing process, you can mal-reduce a fracture which has been previously well reduced during the nailing process.
ASHOK GAVASKAR: Thank you.
HITESH GOPALAN: Thank you, Sunil, for that brilliant talk of yours, and you've covered almost everything about technical tips. And I remember the good old days when we started doing the gamma nail and the cyrus nail and how difficult it was to get people convinced that the intramedullary nailing is going to be the future.
HITESH GOPALAN: Ah Sunil, a couple of questions. Now, not one is regarding, I guess. Yeah, one is regarding the technical tip where you showed that particular paper from South Korea, where they've used an artery forceps ANOK GAVASKAR [I lost you mate]. Sunil, can you hear me? Yeah, yeah I can hear you, now. Yeah so the question is, you showed a paper where they've used an artery forceps to do that internal rotation moment right?
HITESH GOPALAN: Do you think a Hommand spike would be a better thing, do you think artery forceps could do that interrogation, because it's very strong, muscular. Right Yes. So do you think a Hommand spike would be a better choice?
ASHOK GAVASKAR: Yeah possible, you can use it. OK you can use it.
ASHOK GAVASKAR: Probably something with the day of use artery use is a plantar plan. I use a car called with the long handle most of the times and I tend to start off like, use it. as posteriosly as possible. Start so.
ASHOK GAVASKAR: So I'm then let go again. As I said, like as you said, a Hommand shouldn't be a bad choice any it's just an instrument like anything that goes under the vastus to make use of the vastus brutalial attachment relationship to bring in internal rotation.
HITESH GOPALAN: Thank you, Sunil, for that. And the other question is, see, what has happened in last 10 years is not subtracting.
HITESH GOPALAN: If you talk about intra-trochantric as well, everyone is going towards this particular [INAUDIBLE] Right? Everyone is obsessed about putting AP, F and and A2. OK? And do you think there are significant complications with AP and F and A2 like a femoral head perforation and androgenic lateral perforation? And do you think a AP and F and A2 has more complications compared to a regular PFM? What does the AO dictate?
ASHOK GAVASKAR: Yeah so I think like a few things. Like if you mean by a regular BFM, if you mean the two screws that AO sometime introduced, I think that is probably, in my opinion, like we never had that AO device in India actually. Like we had only the Indigenous made a two screw fence which came in eight and six, seven screws. But if you look at the AOP sets like that's 11, the weight bearing is actually 11 and we never had it there actually.
ASHOK GAVASKAR: But so when you have an eight, nine, six, seven, six, seven screw is an anti rotation screw where the one they screw is the weight bearing screw. I thought that was not a great construct to deal with the geriatrics sub drug facts are a drug factor. So so I'm not when you say a regular patient that is not my go to Device. But I think gamma OK or any screw based device, I think when the blade came, it was thought that would give you superior outcomes compared to a screw.
ASHOK GAVASKAR: But I really don't think so because like we used it for five years continuous and we published our results in 2013 I think, we reported a 30% complication rate over the BFD and A2. So I and if you look at subsequent literature after that and there are quite a few papers in Brazil, ones that report that the number of complications are probably more with blades and also the blades
ASHOK GAVASKAR: do not give you superior outcomes even in osteoporotic fractures. I don't think they are better than a screw, so I'm quite convinced with regards to that. So right now, like the thing is like I use blades, I don't use the PFNA, but I use that for the, the more recent one. But, but I, but I agree with you. But the PFNA, I think there are certain design and design advantages compared to APF.
ASHOK GAVASKAR: Definitely but right now, like my go to device would still be a screw based implant for the osteoporotic sub-troch fracture. I use a PFNA or BFNA in select situations.
HITESH GOPALAN: Now what is the difference between a DFNA and a trochanter fixation like the DFN? What are the design difference?
ASHOK GAVASKAR: Yeah so if you look at the lateral profile of the BFNA, it's much lower.
ASHOK GAVASKAR: So that it is, it allows you to input it inside easier and also lessens the possibility that you might break the lateral wall once and then like there is a possibility to compress and then you hold your fixation. That was not possible, I think if you look at the concept with the integrated lag screws from Smith & Nephew, if you like, the concept is we always used to believe that these fractures should be allowed to slide and collapsed during the process of fracture healing.
ASHOK GAVASKAR: That is how we have been taught. But I think there is good enough evidence right now that you can compress these fractures on table under vision in a very controlled manner, rather than relying on dynamic collapse that happens during fracture healing, which may not be under your control at all. So once you have done that, got your fractures fixed in a manner that you want, you stop everything, don't allow any more sliding.
ASHOK GAVASKAR: So those kind of concepts have shown initial success in initial good success as well. So right now the BFNA design allows you to do that. So where you can kind of completely lock it so that you don't allow your fracture to collapse, or if you want to allow it to collapse, still you can do it. So you have the option of doing it both, and that is the current kind of design concepts most people believe in.
ASHOK GAVASKAR: So I think that has benefits. And you might, you, you might remember we published our results as well like you like where we compared both and we and not in terms of major complications. But there were certain advantages with the integrated lags compared to a blade.
HITESH GOPALAN: Thank you, Sunil, for that. Just one last question before we wind up the session.
HITESH GOPALAN: Are there situations where you don't want to use an intermedullary nail, for example, is there a contraindication and where you would prefer a locking plate, OK a proximal femoral locking plate?
ASHOK GAVASKAR: Yeah so for me. Proximal, if you ask me. I use a plate, yes, I use a plate.
ASHOK GAVASKAR: The most common indication for me to plate a proximal femoral fracture will come in a revision situation where I use a blade plate, sometimes alone. or some times I will use an anteriol plate, but in a primary situation. I very rarely use blade plates, proximal femoral plates yes I have used it but very few times. My indication for using a plate in a primary situation is like when I have a lateral wall that is completely floating where it has no kind of relationship with the proximal fragment.
ASHOK GAVASKAR: So in this case, it's like my options are; go get reduced the lateral wall to the proximal and the distal fragment and then go again with my stabilization. So in this scenario, there are a few instances where I have gone ahead with the proximal femoral lock plate because here, unless you reduce it, I don't plate my lateral wall in all fractures as some people do it.
ASHOK GAVASKAR: So there are some proponents who say whenever a lateral wall is fractured, they should plate that as well and there are some innovative designs where they have a nail and a plate going together as well. So but we don't do it that way. But I mean, whenever my lateral wall is completely floating, in those instances, I go or get dual open reduction and from there on
ASHOK GAVASKAR: it's either a proximal femoral plate or a nail with an additional lateral plate, a low profile one.
HITESH GOPALAN: Thank you, Sunil. Sunil, I think that's all the questions that we have for this session. Fantastic lecture and I'm sure this lecture is going to benefit a lot of people all over the world.
ASHOK GAVASKAR: Thank you so much mate. Thank you so much. Thanks for the invitation.
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