Fractures of the Proximal Femur: Improving Outcomes

Copyright
Contents
Contributors
Preface
Foreword
Epidemiology/Population Studies: Scope of the Problem
	Frailty
	Falls and Fractures
	After the Fracture
	Summary
	References
Skeletal Assessment of Fractures of the Proximal Femur
	Radiologic Evaluation
		Computed Tomography
		Magnetic Resonance Imaging
		Bone Scan
	Special Types of Fractures
		Avulsion Fractures
		Pathologic Fractures
		Stress Fractures
	Summary
	References
General Assessment and Optimization for Surgery
	Medical Assessment of a Patient with a Hip Fracture
	Epidemiology and Outcome
	Perioperative Complications
	Optimal Timing of Surgery
		Does Delay to Hip Fracture Repair Result in Worse Outcomes?
	Determinants of Perioperative Risk
		Surgery-Specific Risk
		Patient-Specific Risk: Acute Derangements in Physiology and Homeostasis
		Patient-Specific Risk: Acute Derangements of the Cardiovascular System
	Cardiac Risk Assessment
	Cardiac Risk Optimization
		Coronary Revascularization
		Beta-Blockers
		Alpha-2 Agonists
		Statins
		Valvular Heart Disease
	Etiology of the Fracture
		Fall Resulting in Hip Fracture
	Pulmonary Risk Assessment and Optimization
	Diabetes Management and Optimization
	Liver Disease Assessment and Optimization
	Perioperative Renal Dysfunction and Optimization of the Patient with Renal Disease
	Dementia and Delirium
	Prevention of Venous Thrombosis and Thromboembolism
	Anticoagulant Management
	Antiplatelet Agent Management
	Summary
	References
Regional versus General Anesthesia for Fractures of the Proximal Femur
	General Anesthesia
		Preoperative Preparation
		Technique
		Benefits
		Risks
	Regional Anesthesia
		Options
		Techniques
		Benefits
		Contraindications
		Risks
	Special Considerations
		Postoperative Cognitive Dysfunction
		Time and Cost Issues
	Summary
	References
Improving Pain Management and Patient Outcomes Associated with Proximal Femur Fractures
	Pain, Acute Pain, and the Prevention of Chronic Pain
	Multimodal Balanced Analgesia
	Undertreatment of Pain
		During Hospitalization
		After Hospital Discharge
	Assessment of Pain
		Multidimensional Tools
		Unidimensional Tools
		Observational (Behavioral) Tools in Elderly Patients with Cognitive Impairment
	Pharmacotherapy: Drugs Commonly Used in Multimodal Analgesia
		Acetaminophen
		Nonsteroidal Anti-inflammatory Drugs
		Duration of Action and Potency
			Cardiovascular Risk
			Bone Healing
			Gastrointestinal Complications
			Optimization in Pain Control
		Opioid Therapy
			Underuse and Underdosing in Pain Control
			Opioid Receptors
			Morphine
			Codeine
			Hydromorphone
			Oxycodone
			Meperidine
			Fentanyl
			Methadone
			Tramadol
			Mixed Agonist-Antagonist Opioids and Partial Agonist Opioids
			Naloxone
			Oral and Parenteral Delivery Routes
			Use of Patient-Controlled Analgesia and “Given When Needed” Analgesia
			Elderly Patients and Opioid Drugs
			Complication Limiting Opioid Use
				Delirium and the Undertreatment of Pain
				Opioid-Induced Respiratory Depression
				Monitoring for Respiratory Depression
			Use of Naloxone
		Gabapentin and Pregabalin
	Regional Anesthesia and Pain Control
		Fascia Iliaca Block
		Femoral and Lumbar Plexus (Psoas Compartment) Blocks
		Neuraxial Opioid and Morphine Sulfate Extended-Release Liposome Injection (DepoDur)
	Optimizing Pain Management
	References
Femoral Neck Fractures:  Reduction and Fixation
	Defining the Injury
	Classification
		Historical Background
		Classification System of Garden
		Classification System of Pauwels
		AO Classification
		Classification System of Linton
	Diagnosis
		Conventional Radiography
		Advanced Imaging
	Treatment Options
	Nonoperative Treatment
	Operative Treatment
		Nondisplaced Femoral Neck Fractures
		Displaced Femoral Neck Fractures
		Fixation Options
			Internal Fixation with Multiple Cancellous Lag Screws
			Internal Fixation with Sliding Hip Screw Devices
		Reduction Techniques
			Closed Reduction
			Open Reduction
		Fixation Techniques
			Cannulated Screw Fixation
			Dynamic Hip Screw Fixation
	References
Femoral Neck Fractures: Arthroplasty
	Indications
		Examination
	Imaging
	Treatment Options
	Surgical Technique
		Anesthesia and Positioning
		Exposure of the Femoral Neck and Removal of the Femoral Head
		Acetabular Preparation
		Femoral Preparation
		Implantation
		Wound Closure
		Postoperative Considerations
	References
Combined Fractures of the Hip and Femoral Shaft
	Incidence
	Mechanism of Injury and Pathophysiology
	Initial Diagnosis and Assessment
	Management Options and Controversies
	Improving Outcomes
	Areas of Uncertainty
		Should a Displaced Femoral Neck Fracture Be Fixed before Fixation of the Femoral Shaft?
		What Type of Implant Should Be Used for the Femoral Shaft Fracture?
		Do Cephalomedullary Nails Provide Improved Fixation?
	Complications
	Summary
	References
Femoral Neck Fractures:
Treatment of Nonunion
	Diagnosis and Preoperative Considerations
	Salvage Procedures
		Proximal Femoral Valgus Osteotomy for Femoral Head Preservation
		Bone Grafting for Femoral Neck Fracture Nonunion
		Total Hip Arthroplasty for Femoral Neck Fracture Nonunion
	Summary
	References
Trochanteric Fractures: Sliding Hip Screw
	History
	Construction and Biomechanics
	Indications
		Classification of Trochanteric Fractures
			Clinical Relevance
		Revised Concept of Instability of Pertrochanteric Fractures
		Comparison of Sliding Hip Screw and Intramedullary Hip Nail
			Biomechanics
			Surgical Technique
			Biologic Benefits
			Comparative Clinical Studies
	Preoperative Planning
		Radiologic Examination
		Contraindications
		Selection
	Surgical Technique
		Patient Positioning on the Fracture Table
		Positioning of the Image Intensifier
		Reduction
		Final Radiologic Preoperative Assessment
		Draping
		Approach
		Fracture Fixation
		Wound Closure
	Postoperative Management
	Specific Complications
	References
Trochanteric Fractures: Intramedullary Devices
	Aims of Treatment
	Rationale for Intramedullary Nailing of Extracapsular Hip Fractures
	Indication and Fracture Types
		Ao/Ota 31A1
		Ao/Ota 31A2
		Ao/Ota 31A3
	Operative Technique
		Positioning
		Reduction
			Closed and Percutaneous Reduction Techniques
				Gaining Control of Flexion Dislocation
				Control of Varus Angulation
			Open Reduction
		Skin and Fascial Incision
		Nail Entry Point
		Lag Screw Positioning
		Interfragmentary Compression
		Static or Dynamic Mode
		Distal Locking
		Intramedullary Nails in Segmental Fractures
	Postoperative Management
	Implant Removal
	Pitfalls of Intramedullary Devices
		Cephalomedullary Nails with a Single Interlocking Screw
		Cephalomedullary Nails with a Lag Screw and an Antirotation Screw or Pin
	Next-Generation Cephalomedullary Nails
	Summary
	References
Complications of Trochanteric Fractures
	Overview of Complications
		Intraoperative Complications
		Complications During Surgical Wound Healing
		Complications During Fracture Healing
		Complications Developing or Persisting After Surgical Site or Fracture Healing
	Inadequate Reduction
	Injury of Pelvic Vessels by Guidewire
	Incorrect Position of the Lag Screw in the Femoral Head
	Rotation of the Femoral Head During Insertion of the Lag Screw
	Incorrect Length of the Lag Screw
	Problems During Nail Insertion
	Problems with Distal Locking
		Problems with the Instrumentation Set
	Wound Healing Disturbances and Infection
		Causes
		Prevention
		Treatment
	Mechanical Failure of Internal Fixation
		Causes
		Levels of Mechanical Failure
			Proximal Level
			Fracture Level
			Distal Level
		Prevention
		Treatment
	Collapse of Fragments and Medial Displacement of the Femoral Shaft
	Central Perforation of the Femoral Head by the Lag Screw
	Migration and Intrapelvic Protrusion of the Lag Screw
	Necrosis of the Femoral Neck
	Delayed Union, Nonunion, and Malunion
	Leg Length Discrepancy
	Postoperative Fracture of the Femoral Shaft
	Subcapital Fracture of the Femoral Neck
	Thigh Pain
	Abductor Pain
	Injuries to Femoral Vessels
		Type of Fracture
		Mechanism of Injury
		Time to Development
		Clinical Diagnosis
		Imaging Methods
		Prevention
		Treatment
	Avascular Necrosis of the Femoral Head
		Incidence
		Causes
		Risk Factors
		Time to Development
		Classification and Stage of Development
		Diagnosis
		Prevention
		Treatment
	References
Subtrochanteric Fractures: Intramedullary Fixation
	History
		Küntscher Y-Nail, Detensor
		Zickel Nail
		Russell-Taylor Nail
		Gamma Nail
		Gliding Nail, Proximal Femoral Nail, Proximal Femoral Nail Antirotation, Targon-PF
		Letzius Nail
		Küntscher Condylocephalic Nail
		Ender Nailing
	Classification
		Boyd and Griffin
		Fielding and Magliato
		Zickel
		Seinsheimer
		Waddell
		Russell and Taylor
		Ao/Ota
	Preoperative Planning and Choice of Implant
	Operative Technique
		Patient Positioning
		Fracture Reduction
		Surgical Approach
		Entry Point
		Preparation of the Medullary Canal
		Nail Insertion
		Lag Screw Insertion
		Distal Screw Locking
		Wound Closure
	Follow-up Care and Physical Therapy
	Common Surgical Errors
		Incorrect Reposition
		Trochanteric-Diaphyseal Distraction
		Incorrect Introduction of the Nail
		Nail Incarceration
		Fracture of the Lateral Cortex of the Femur
		Fracture of the Femoral Shaft by the Nail
		Incorrect Position and Length of Lag Screws
		Problems with Distal Locking
	References
Subtrochanteric Fractures: Plate Fixation
	Epidemiologic, Anatomic, and Biomechanical Overview
	Classifications and Stability
		AO Classification
		Russell-Taylor Classification
		Seinsheimer Classification
		Waddell Classification
	Therapeutic Plate Options
		95-Degree Condylar Plate
		95-Degree Dynamic Condylar Screw
		135-Degree Compression Plates (Dynamic Hip Screw)
	Complications and Pitfalls
		95-Degree Condylar Plate
		95-Degree Dynamic Compression Screw
		135-Degree Dynamic Hip Screw
	Salvage Procedures
	Outlook
	References
Deep Vein Thrombosis and Thromboembolism: Prevention and Treatment in Hip Fracture Patients
	Incidence
		Fatal Pulmonary Embolism
		Symptomatic Venous Thromboembolism
	Pathogenesis
		Hypercoagulability
		Venous Stasis
		Endothelial Damage
	Prophylaxis
		General Measures
			Early Mobilization
			Neuraxial Anesthesia
		Mechanical Methods
			Graduated Compression Stockings
			Intermittent Pneumatic Compression Devices
			Foot Pumps
		Chemical Methods
			Aspirin
			Warfarin
			Low-Molecular-Weight Heparins
			Pentasaccharide
			Direct Anti-Xa Inhibitors and Direct Thrombin Inhibitors
		Combined Methods
		Duration of Use
		Guidelines
	Summary
	References
Investigation and Management of Postoperative Delirium
	Definition
	Epidemiology
	Pathophysiology
	Diagnosis
	Risk Factors
		Preexisting Patient Factors
		Intraoperative Factors
		Postoperative Factors
	Prevention
	Management
	Summary
	References
Rehabilitation: Improving Outcomes for Patients Following Fractures of the Proximal Femur
	Issues in Rehabilitation Care for Patients with a Fracture of the Proximal Femur
		Patient Characteristics
		Health Care Services Issues
		Cost of Care
	Reframing Rehabilitation Across the Health Care Continuum
		SIGN Guidelines for the Prevention and Management of Hip Fracture in Older Persons
		“Blue Book” for the Care of Patients with Fragility Fractures
		Total Joint Network Integrated Model of Care
		Model of Care for Patients with a Hip Fracture
	Principles of Optimized Rehabilitation Care
		Access and Patient Flow Across the Health Care Continuum
			Timely Surgery
			Transition Between Services
			Discharge Planning
		Optimal Clinical Practice
			Surgery to Maximize Functioning
			Optimal Medical Care
			Clinical Pathways
			Management of Delirium, Dementia, and Depression
				Delirium
				Dementia
				Depression
				Screening and Management of the Three Ds
			Functional Activity
				Early Mobilization
				Weight-bearing Status
				Rehabilitation Scheduling
				Considerations for Those with Frailties or Cognitive Issues
			Community Care
		Secondary Prevention
			Osteoporosis
			Falls Prevention
		Performance Measurement and Model Implementation
			Performance Measurement
			Model Implementation
	Summary
	References
Preventing the Second Hip Fracture: Addressing Osteoporosis in Hip Fracture Patients
	Patient Profile
	Fracture Risk Assessment
	Determinants of Future Fracture Risk
		Advanced Age
		Prior Fragility Fracture
		Tendency to Fall
		Vitamin D Insufficiency or Frank Deficiency
		Secondary Osteoporosis
	Bone Mineral Density
		Does the Elderly Patient with Hip Fracture Require Bone Mineral Density Testing for Osteoporosis to be Optimally Managed?
	Components of an Effective Osteoporosis Care Strategy
		Correction of Vitamin D Insufficiency or Deficiency
		Calcium Supplementation
		Falls Prevention
		Bone Mineral Density Testing
		Education and Motivation of the Patient
		Pharmacologic Treatment
		Adherence to Osteoporosis Treatment
		Involvement of Different Specialties
	Barriers to Osteoporosis Care
		Patient-Related Barriers
			Advanced Age
			Cognitive Impairment
			Comorbidity
			Polypharmacy
			Patient Frailty and Social Isolation
		Physician Barriers
		System Barriers
			Cost and System of Remuneration
			Postfracture Care Environment
	Systems Approach to the Management of Osteoporosis
	What Is the Role of the Orthopaedic Surgeon?
	Summary
	References
Best Surgical Practices
	Overview
	Optimal Surgical Tactic
		Postoperative Weight Bearing
	Surgical Strategies
		Intracapsular Hip Fractures
			Overview
			Femoral Neck Fractures: Definitions
			Stable Femoral Neck Fractures Should be Fixed
			Unstable Femoral Neck Fractures: Replacement 
Versus Fracture Fixation
				Fracture Fixation Tips, Tricks, and Controversies
					Reduction.
					Fixation.
					Replacement.
		Extracapsular Fractures
			Overview of Surgical Strategies
			Pertrochanteric Fractures with Intact Lateral Cortex (Types 31A1 and 31A2)
				Type 31A1 Fractures
				Type 31A2 Fractures
				Fracture Fixation Tips, Tricks, and Controversies
					Dynamic Compression
					Bridging Fixation
					Replacement
			Pertrochanteric Fractures with Lateral Cortical Fracture (Type 31A3)
				Fracture Fixation Tips, Tricks, and Controversies
					Compression
					Bridging Fixation
					Replacement
			Subtrochanteric Fractures
	Summary
	References
Best Rehabilitation Practices
	Overview
	Organizing Rehabilitation Services
		Definition of Rehabilitation
		Rehabilitation Setting
		Rehabilitation Program
		Bridging the Health Care Continuum
			Direct Home with Outpatient Care
			Free-standing Rehabilitation Hospital or Acute Care Hospital with an Inpatient Rehabilitation Unit Inpatient Rehabilitation ...
		Inpatient Rehabilitation Services: Guidelines for Common Medical Issues Encountered During Rehabilitation
			Delirium
			Medical Comorbidities
			Cognitive Impairment and Dementia
				Diagnosis of Dementia
				Management of Dementia
			Pain Management
			Psychiatric and Psychological Issues
		Inpatient Rehabilitation Services and Interprofessional Care: Concept and Guidelines for Common Rehabilitation Issues
			Early Mobilization
				Therapy in the Nonoperative Group
				Therapy in the Postoperative Group
				Functional Performance
			Discharge Planning
			Environmental Assessment
			Social Support Assessment
	Community Reintegration
		Ongoing Interprofessional Care
		Prevention of Falls
			Prevention of Falls in the Community
			Prevention of Falls in Care Homes
		Prevention of Fractures: Osteoporosis
	Functional Independence Measure Score
	Summary
	References