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At wearing and my talk this week is about hip fractures. Can you hear me? All right, I think I've got my microphone. Yeah. Fantastic, brilliant. Thank you. So, hip fractures are an incredibly wide and detailed topic and it's, there's so much that can be said about it and there's so much information. Er so it's quite hard knowing what exactly to put into this talk. So I've tried to keep it as succinct as possible and uh keeping relevant topics as well as concepts that I found a bit difficult to comprehend at times. But um if you feel that I've gone over anything a bit too fast or you want me to reiterate something, please do uh write a message on the side. Um So we're gonna start this uh oh gosh, just gonna start this talk with a quick introduction, discuss the risk factors, differential diagnosis of someone who presents with hip pain. Then a little chat about the relevant anatomy, er, classification of hip fractures, um management of the, the, the four kind of more hormone modalities that we see in, in practice. Um and then some concepts relating to um hip er arthroplasty. So a very, very quick introduction. So, hip fractures are incredibly common, the most recent data suggest 76,000 on an annual er on an annual basis across the United Kingdom as a whole. Er and it's got a lot of um significant mortality associated with it. Uh We know this from the from where we see patients who present with neck of femur fractures in A&E er hence the formation of the goal service framework incorporating orthogeriatrics who uh try and ensure a holistic um approach for these patients who are often very very frail and for some patients, a fractured Neema is their first kind of um overt presentation of their frailty. Um sadly, 10% of patients despite these efforts die in the first month and a further third tend to pa um die following the injury which are very, very high figures. Hence, uh there's still a focus for the goal goal service framework in er trying to ameliorate this risk factors for a hip fracture. Age is a is a, is a, is a, is probably the predisposing one osteoporosis which is more common in women, especially post menopausally due to the lack of estrogens, uh protective effect on bones. So, therefore, amenorrhea is linked with a lower er circulating estrogen amount. Smoking has a negative effect on bones as does uh excess alcohol, both directly and indirectly, physical inactivity has also been implicated uh both indirectly and directly indirectly through the associated metabolic syndrome. It can incur but also actively through reduced load bearing through bones as well as high dose corticosteroids which act to thin the blood promote osteoporosis. Uh previous fragility fractures or falls are also another main risk factor. Uh A low BM I again through reduced uh load strain through the bone. Um previous malignancy as well, especially with the risk of uh metastatic disease is a risk factor. Things to think about with a differential diagnosis. I mean, most of the time when patients present to an accident emergency ward, they'll promptly get an X ray and the diagnosis is often quite clear that um um um but uh alternative fracture sites are always er risks as well such as pubic re my fractures, er, ace tablet fractures and shaft fractures. Another important differential to think about is er hip dislocation, which should be, you'd hope clinically apparent, but also uh should be evident radiologically osteomyelitis. Whilst it's a much rarer differential is something to think about X ray findings might not be immediately uh apparent. And if osteomyelitis is clinically um implicated, then appropriate radiological investigations and discussion with microbiology is warranted. Um And then in uh pediatric patients slipped up. A femoral per epiphysis is something to think about avascular necrosis of the femoral head is also something to think about, especially in patients who've had previous injuries, uh previous uh neck of feur fractures. Uh So you very simply put the hip joint to the synovial joint uh lined by hyaline er cartilage, um, with um, the sinovial joint encompassing the femoral head and the neck. When we talk about the acetabulum, we're talking about the union of the ilium pubis and ischium, the three bones and the femoral head is connected to the femoral shaft via the femoral neck. Uh, the angle between the neck and the medial aspect a range that's commonly quoted as 100 and 20 to 100 and 40 degrees. But the f literature suggests 100 and 27 degrees is the er number that er is er normally there, the vascular supply to the hip, it underpins our management approach uh strategies for neck of feur fractures. Uh The main vascular supply is this medial femoral circumflex, which is a branch of the femoral artery. Um and it, it divides into two branches. Um and then they also divide again, giving the nutrient arteries which provide the femoral head uh with blood. The other important thing especially for exams to think about is the inferior gluteal arteries which provides support and a an anastomoses with the medial femoral circumflex. And really this, this vasculature is the key er feature as I alluded to earlier as to why we manage our neck of femur fractures, the way we do, er, it's all to do with interrupted supply. Well, the risk of interrupted supply from to the femoral head. Uh So when we think about uh fractures neck feur fractures, we incorporate this intracapsular versus extracapsular system. So, er anything that's intracapsular, er we consider it to be at risk of having its er vasculature affected. And so this um the potential for that to be affected. And so therefore, that's why we think more about managing it with replacement rather than repairing, but that this is something I'm going to go into in a moment. Um and it's just, just useful to kind of have a look at these terms. So, subcapital ba survival and then looking at these intertrochanteric er here between the two trochanters and then subtrochanteric which is five centimeters below the lesser trochanter. Um whenever I found clinically, sometimes you can find intertrochanteric fractures that extend into the subtrochanteric region. This is really important something to plot because it will affect our management of how we do this and its inherent stability. So uh this is an X ray er of intracapsular neck of femur. Er just you can see for those who are on that used to looking at x rays, we can see quite clearly here, the great and the lesser trochanter and you can see the femoral head here and you can see that there's this er impacted fracture at this site here. Um So when we talk about intracapsular fractures, this this slide at first, it seems a bit overwhelming, but it's actually quite a logical way of thinking about it and I've updated it from the the most recent nice guidelines from January of last year uh regarding um management. So, in an elderly patient who's displaced their fracture, we're worried about their vasculature. So we're thinking, uh we're worried that that vasculature has been affected, so we're thinking about replacement. So we're replacing either with a total hip replacement or hemiarthroplasty. And what's important to think about is the baseline um uh mobility stats and how they are as a patient. Are these well and fit patients er, for their age. So we can't just look uni dimensionally at age as being at the sole criteria are these patients who live a very active lifestyle, walk, often uh walk independently, don't have very life depending, er, comorbidities uh able to er carry out their activity daily living. If so, we should consider total hip replacements rather than hemiarthroplasties. Now, when we look at young patients, sometimes we might slightly change our management um protocol. Um so as undisplaced fracture in a, er, a young, so less than 65 sometimes we think about internal fixation, er, with a dynamic hip screw. For example, the rationale with this is we're trying to promote their er natural tissue whenever we put an implant in, it is uh not something that the body can regenerate itself. So it is uh subject to wear and tear and this is something I'll talk about later on. But uh this can have an impact upon that. So, in younger patients, it, we might be doing them more of a favor by keeping their uh natural tissue by using internal fixation, especially if it's not displaced. Um There's a classification system for this, the garden system which we'll touch on later on benefits of this is that like I said, we're retaining uh natural tissue. So we're kind of giving them a, a longer life um lifespan of their native tissue, uh not predisposing them to needing surgery and revision surgery. The trade off is w a total hip replacement also is a treatment for arthritis, which if in a young person, admittedly, you think lower risk of getting arthritis, but if they do have coexisting arthritis, we're not gonna be managing that with internal fixation. Um So this is the garden classification that I was mentioning earlier on. So this is really, really useful for thinking about how displaced um er um intra caps neck of feur fracture is. So garden one, you can see the, the fracture line doesn't extend throughout the, the neck. It's relatively undisplaced. Um Sometimes the head can be pushed into a valgus position. Compare contrast that with a garden stage two where it's the fracture line has extended all the way throughout, but we've still got that preserved um kind of angle. It's not uh it's not displaced at all. Um In garden three, you've got a fracture line that goes completely through. This photo is a little bit misleading, but essentially what you want is a lack of continuity between the fracture. And so it's slightly displaced. And a garden stage four, you can see there's complete discontinuity between the head and the, the rest of the femur and one and two would be where we would think about in young patients, potentially. Could this be something we can manage with internal fixation? Whereas three and four inherently unstable and we'd need to think about replacement instead. Uh There are other systems like the Powell classification, er, as well as AO have their own er alpha numeric system for looking at this. But er, ii always find that the Garden classification, it's, it's, it's very easy to apply to real life clinical practice and it's quite widely used um throughout the UK. So I'll take a little segue here to talk about just the history of total hip replacements. I find it amazing that we're 100 and four, nearly 100 and 40 years since the first attempted, er, earliest recorded attempt where, er, it was actually not for trauma but for um bone er damage by tuberculosis, which was a lot more prevalent back then. And ivory was used presumably because it was thought to be a, a similar kind of construct. Um later on in the 19th and 20th century, um they moved on to trying to use interpositional arthropathy. Er, so by putting various types of tissues such as pig bladder, submucosa between articulating hip surfaces to try and stop that wear and tear down, uh, by the 19 twenties they moved on to trying to use glass as, as a substrate over the femoral head which despite it not uh, causing any kind of immune response, it was quite brittle and wouldn't withstand the forces. Er, it wasn't until 1953 in, er, Norwich when George mckee used the first metal metal prosthesis with um, a cemented hemi arpa using cobalt and chrome, um, which, which looked in initially was, was revolutionary, but then started having issues with er, metallosis, er, especially during revision surgery. A lot. Unfortunately, a lot of these then started failing and then f er revision surgery was compounded by the issue with soft tissue absorbing metal ions. Um And then, so John Charnley er, was revolutionary by the 19 sixties coming up with this concept of low friction arthroplasty where he was thinking a smaller femoral head means less wear and tear because you've got a smaller acting surface area and you know, kind of revolutionized the kind of concepts we think of now a femoral stem, a polyethylene acet tablet component and acrylic bone cement. And it's, it's taken us to this kind of debate on really what is the best um combination should we look at metal on polyethylene metal, on metal or ceramic, on ceramic? And both of them have their advantages and disadvantages and you're kind of trading off essentially strength, mechanical strength versus uh wear and tear loosening. Um er, release of ions. And um so at the moment, different clinicians will have different views. Certainly metal and polyethylene tends seems to be a very preferred um uh management modality, er despite the risks of aseptic loosening. So when we talk about total hip replacements, we talk about replacing the femoral head and the neck as well as the acetabular surface. Uh like I said, we, this is the kind of treatment modality for displaced femoral neck fractures in the very active healthy um uh individuals as well as um it is also a treatment modality outside of the fracture world for um arthritis. Um because of the additional steps and um required for this, this tends to be the preserve of uh hip surgeons rather than um generally a all orthopedic specialists. Um and compare this with the hemi arthroplasty where we really um you've got the femoral head but you're retaining the na native aceta less complicated. So it's better for um less active elderly patients. It's got a lower risk of dislocation. Um It's a bit shorter operation but it doesn't address arthritis. So, uh you might revision surgery might be something that is needed down the line. So this is something to bear in mind when uh consenting patients and discussing the benefits for and against. Um So there's um a difference in whether we can go cemented versus uncemented. Um You're out quite referring to the acetal cup as well as the stem, er, cemented stems include stuff er like exeter stems which are these ones here which are quite, you can see they're very smooth, they're highly polished and they work on the process er concept of micromotion. So by having micromotion at the interface between the metalwork and the cement, you get a slight bit of subsidence of the stem and that gives you a compression at the er interface. Er the an alternative way is this Charnley stem. Well, this is uh sorry, a composite beam which is an example would be one of these Charley stems where they work through getting a solid bone between stem cement and bone, but you there is no subsidence uh between it. The cement works as a grouse to basically interlock between the bone and the prosthesis. Um And this, this was the initial kind of the early favored kind of er approach. Er but unfortunately, it was high rates of losing in osteolysis, which led people to think about uncemented um which er have either we have these kind of rigid you can see on this cry stem here. Oh, she wears my mouse on uh there's the C stem there. Actually, you've got these um edged surfaces and they work either on the concept of growth or ingrowth. So there's on, there can be hydroxy appetite which causes a textured surfaces to stimulate bone growth onto it or they can work by having microscopic pores to generate um bones growing into it. There's a large range of designs available as you can see here. Uh We, you know, a lot of research has gone into changing the stem design and the stem length to try and recreate natural physiological um load bearing. Um And a lot of this is kind of deal. Um surg surgeons will ex have a preference from their own clinical um practice, what they've trained with, what they've worked with, what they've seen during their own training, what they think works better and what they think works better in their own hands that they feel more confident with. Um the initial stability, the um the stability that, that, that these uncemented ones um generate is very, very important because if you have too much micromotion, then you actually generate virus tissue. So you want to aim for micromotion of less than 20 micrometers. And then instead of generating fibrous tissue, you tend to generate predominantly bone. Um So we've talked about and I appreciate this is a very whistle stop tour. I'm I'm talking about 100 miles per hour here. Uh It's, it's I just quickly see if there's any questions or I will, I'll discuss questions at the end. But um um just moving on from intracapsular to extra capsules. So here we can see an intertrochanteric uh fracture, which is an example of a extracapsular fracture. Now, in these ones, because we, we're not as worried about blood supply. We think about fixing rather than replacing Um Now, if subtropic reverse oblique fractures are inherently unstable. And so, uh we need to think about different treatment modalities. So, in the UK, we have this kind of duality between dynamic hip screws and intramedullary nails. Interestingly, this tends to be quite a British focused approach. We actually never knew that dynamic hip screw is a trade name for a sliding hip screw. Um And internationally, there's a much more of a vague for intramedullar renail for all intra extracapsular fractures. But in the UK, we tend to look at it. If they're in intertrochanteric, we use a dynamic hip screw uh or uh a subtrochanteric or reversible blades. We think about intramedullar R nails. The other indication for a dynamic hip screw is, as I mentioned earlier in a young patient with a N undisplaced intracapsular necho feur. Sometimes, er if we're, if it's undisplaced, we make the assumption that the vasculature hasn't been threatened, then we will try to repair with the DHS um as well. But that's, that's kind of like by the aside. So as I mentioned D HSS or their official term are sliding hip screws, er where by the placement of a big lag screw, er which is held in by a femoral plate on the lateral aspect. And as the lag screw slides in, uh it compresses the f fracture. So you can see here. So this is the screw here, the lag screw and you basically trying to compress at this fracture line here, you can also add in derotation screws to prevent rotation. Uh So DHS is a trade name by synthes. The benefits for these are lower blood loss and operative times. So they're quicker operations. Hence why people often talk about De HS as being sho operations cos they're good ones to practice on and get, get your uh theater experience up on. They're cheaper implants and they're operatively relatively simplistic uh with a intramedullary now, which provide a much stronger mechanical fixation, they can restore axial alignment as you can see here and prevent angulation. And if you look them, they can provide rotational control. Um there are um cases where you can't use it. So if you've got a very small medullary canal, then you, these are generally not as good an option. Prior deformity such as mal union and in infected fractures, which I wasn't aware of uh grossly contaminated, contaminated, openly infected fractures are contraindications as well. But advantages of these would be a lower non union rate. Um less invasive implant insertion and allow a risk for wound complications. So we've seen this when we look at the wounds, they're often AAA much smaller incision and then just a couple at distally for where they've locked a nail in. Um just wanted to end off talking about a couple of concepts. Um Number one is offset. This is something that I've heard. We've heard quite a bit in trauma meetings, but I never really fully understood it. And actually the way to think about it is is how far is the femur displaced from the pelvis or how far out the femur is? And I, I'll show you a diagram in a moment but um on how to look at it, but it's important because this will help us recreate the correct articulation of the hip. Um So normally, trauma can cause the femoral head to move away from the hip's normal center of rotation. And by trying to mimic its normal center of rotation, we can ensure good abductor function and reduce wear and loosening of implants. So the way to con conceptualize this is if you draw a line across the top of the obturator foramen here, this, this line x um and then you need to draw a line perpendicular to it here. Line Z um And then when you look at like you need to draw another line perpendicular um sorry, the anatomic along the line of the anatomical line of the femur, and then you wanna look at the distance between the center of the femoral head and these two lines and this is your offset. So th this length here is your offset and it's really important to try and ensure that by comparing it to er the unaffected hip that we are um er doing as good a job as possible. This is admittedly something that's more important in elective work rather than trauma work. But it's still a good concept and it's just something, but since I've understood it, I've been trying to draw myself and, and work it out and it's, it's, it's interesting. I mean, admittedly I'm not at the stage yet where I can free just look at it an X ray and say, oh yeah, the offset's wrong, but by drawing it out, it's a good practice and hopefully with time it'll, it'll get settled in a bit more. Um Another concept is version. So um the way to think about it is you can see here the um the femoral condyles um and you want to, you want to try and see the angle of the axis between that and the transcondylar femoral axis. So in a normal version, we should be getting 10 to 20 degrees. And you can see in retroversion instead of it being such an acute angle, it's a much more, much less acute angle and this is retroverted. Whereas here you can see with the, with the um lines far of the er posterior femoral condyles, far more um higher angle. So this is what we call excessive anteversion. Um So, yes, sorry, I was a bit blunt. There just jumped straight onto references. Um It is really, really difficult to try and keep this in within half an hour. I know, II aim to try and get this within 20 minutes. So we could have a little bit of a discussion, but I'm overshot of it. Um, I hope this has been useful. Um, I definitely found reading into this very, very educational and th this is simply scratching the surface. There's so much information, so much to be gleaned and it's definitely the next time I'm in for a, um, theater for a hemi or a tote or, or, or a D HSI. Definitely gonna be conceptualizing new things that I didn't think about earlier and I hope this has helped you to do the same. Er Thank you very much questions. Oh yeah. Any, any questions? Sorry. Yeah, just looking at the messages now. So thank you for answering that question from Ashok. Um How's that brilliant? Thank you very much. That's ok. Oh, yes, please. Um er er feedback. We really appreciate it. Thank you. Um How many people were locked on for that? I mean that was about 10 now we had no, we had that around 18. Where are they coming logging in for? Um, the one from the uh this is uh E MPI. Don't know if this is, this question is what I would suggest is if we get all these people who are logged on, on the wording site, they come up to the room just be a bit more interactive. Otherwise just you giving a speech or bad about that. I literally just most of the time people want to, but I don't know if that's possible on the system. Half an hour, you are just trying to finish it, trying to lose the interaction, you lose the interaction with it, trying to encourage as much people to come here as possible. Do you think we'll ever have any luck getting in the room in the selection on our teaching system doesn't seem to match. And so II just want to have a regular schedule of teaching than having I get as many people as possible. Actually coming into this room would be good because then at least the people here can interact a little bit. Otherwise it becomes a sort of a very much a monologue type thing and then sort of, um, yeah, it's much better that way. Obviously people on the same side do not in that way and asking this way, it's not ideal either way. But I think if we, um, just try to encourage all these people to come next time to the run, just make a bit better. I'll be, yeah, I'm just trying to think it's not like we have anyone here at 430. Right. Um, is there anything you think I should have for trauma? Four, hip fractures? Mhm. Best not to talk about the history of the total hip fracture so I can play around with the hip fracture. Yeah, because it's sort of not like at all as interesting as some people. I find it interesting that it is crazy that they were using might be interesting for us, but they just want to know, what do you do for in terms? Why do hi, I not feeling conservatively in bed for like, ages, you know, that sort of like the life or death side of it rather than on the elective, sort of interesting bits, which are interesting, but kind of why do you have to fix it? You just leave it, you know, it sounds like an unnecessary operation, that kind of thing because you want to sit up, you a nurse about pain, pain, blood clots, that kind of thing. That's the reason why that's the trauma reason for doing this. True. Um, so I, if I was going to do this again, get rid of like the history of it and then put that in a little bit of that as a way to make it.