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Intertrochanteric Fractures
Posted: Sep 2 2021 #(C101781)
A

Hardware Failure in Proximal Femur Fx s/p GSW in 38M - Part 2 of 2

HPI

A 38-year-old male presents to clinic with right thigh pain ongoing for 3 months status post cephalomedullary nail. The index procedure was performed for a proximal femur fracture that occurred secondary to a low velocity GSW. The patient denies any new trauma or acute changes. The patient denies feeling ill or signs/symptoms of infection. This is a 2-Part Case: Part 1 is titled: Proximal Femur Fx s/p GSW in 38M - Part 1: Fracture and can be found at https://www.orthobullets.com/Site/Cases/View/cffda5ed-7dac-4016-b5dd-242887eb685f)

PMH

Unremarkable

PE

Focused physical exam of the right lower extremity demonstrates a healed GSW entry point anteriorly. Prior incisions from percutaneous nail placement are well healed without erythema or drainage. He is neurovascularly intact.

Poll
1 of 8
1. In addition to plain radiographs, would you obtain any further imaging to guide your treatment?
No - current radiographs are sufficient
22%
156/701
Yes - additional radiographic views
0%
4/701
Yes - CT scan of the hip (CT)
63%
446/701
Yes - MRI scan of the hip (MRI)
2%
17/701
Yes - CT + XR
5%
41/701
Yes - MRI + XR
0%
4/701
Yes - MRI + CT
1%
13/701
Yes - MRI + CT + XR
1%
8/701
Outside my area of expertice, best if I don't vote
1%
12/701
2. Would you obtain any labs in the workup of this patient?
No - not necessary
4%
28/685
Yes - inflammatory markers (e.g. CBC, ESR, CRP)
57%
392/685
Yes - metabolic labs (e.g. Vitamin D, TSH etc.)
2%
17/685
Yes - inflammatory markers + metabolic labs
35%
242/685
Outside my area of expertise - best if I don't vote
0%
6/685
3. If all laboratory workup was within normal limits, how would you manage this patient?
Nonoperative - weightbearing restrictions
3%
24/683
Operative
94%
644/683
Outside my area of expertise - best if I don't vote
2%
15/683
4. If you choose Operative management, what technique would you use?
I would not choose Operative management
0%
4/663
External fixation only (ExFix) (includes monoplanar, ringed circular fixation, etc.)
0%
6/663
Open reduction internal fixation (ORIF) (includes sliding hip screw, blade plate, etc)
32%
216/663
Cephallomedullary nail fixation (CMN) (includes supplementary cables)
41%
276/663
CMN + ORIF
20%
136/663
Outside my area of expertise - best if I don't vote
3%
25/663
5. If you choose cephalomedullary nail (CMN) fixation, what type of implant would you use?
I would not choose CMN
10%
70/651
Piriformis entry, single lag screw (traditional CMN)
3%
24/651
Piriformis entry, double lag screw (Recon nail)
17%
112/651
Trochanteric entry, single lag screw (traditional CMN)
19%
126/651
Trochanteric entry, double lag screw (Recon nail)
42%
278/651
Other
0%
4/651
Outside my area of expertise - best if I don't vote
5%
37/651
6. If you choose CMN, would you use distal interlocking screw(s)?
I would not choose CMN
7%
47/627
No
4%
27/627
Yes - 1
13%
82/627
Yes - 2
68%
430/627
Yes - 3 or more
2%
17/627
Outside my area of expertise - best if I don't vote
3%
24/627
7. If you choose CMN, would you use a form of bone graft or biological augmentation?
I would not choose CMN
5%
33/620
No
12%
80/620
Yes - autograft cancellous bone (e.g. iliac crest)
29%
184/620
Yes - allograft cancellous bone (e.g. morcellised femoral head or freeze dried graft)
9%
59/620
Yes - synthetic graft (e.g. ceramic based)
1%
7/620
Yes - recombinant osteoinductive protein (e.g. BMP, PDGF)
3%
20/620
Yes - autograft + recombinant osteoinductive protein
18%
117/620
Yes - allograft + recombinant osteoinductive protein
6%
40/620
Yes - synthetic + recombinant osteoinductive protein
2%
14/620
yes - allograft + synthetic + recombinant osteoinductive protein
2%
18/620
Yes - other combination of above options
1%
12/620
Outside my area of expertise - best if I don't vote
5%
36/620
8. If you choose CMN, and attain the construct shown below, how would you manage weight-bearing post-operatively?
I would not choose CMN
4%
25/582
Non-weight bearing (NWB)
17%
99/582
Touch-down weight bearing (TDWB)
47%
277/582
Partial weight bearing (PWB, <25-50%)
16%
94/582
Weight-bearing as tolerated (WBAT)
12%
70/582
Outside my area of expertise - best if I don't vote
2%
17/582
PROCEDURE #1 DOP: 12/3/2020

Revision cephalomedullary nailing with cerclage cable, femoral head allograft/PDGF augment placed in fracture and hydroset injected into lag screw defect

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OUTCOMES
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