AOTrauma Webinar:  Why Do Patients Get Infection?

May 30, 2017 14:00 CET

Main Presenter: Olivier Borens, MD (Switzerland)
Chat Moderator: Stephen Kates, MD (USA)

Surgical site infections after trauma are debilitating and costly. They are feared by the surgeon and the patient alike. The incidence of this complication can be decreased by proper preoperative, intraoperative, and postoperative management.
The goal of this webinar is to present easy-to-use tools and strategies that will lead to a decrease in the incidence of infection.

More information and registration...

Infection

Executive Editor: Joseph Schatzker, Peter Trafton

Authors: Ernst Raaymakers, Inger Schipper, Rogier Simmermacher, Chris van der Werken

Proximal femur 31-A3 ORIF

back to skeleton

Glossary

1 Preliminary remarks top

In A3.1 and A3.2 fractures, normally open reduction will be necessary to achieve an adequate reduction. enlarge

The group A3 intertrochanteric fractures are classified according to the fracture pattern. The subgroup A3.1 represents the simple reverse oblique fractures. The subgroup A3.2 are the transverse fractures and the subgroup A3.3 are the multifragmentary reverse oblique fractures with a detached medial fragment including the lesser trochanter.
One should always attempt a closed reduction. If unsuccessful, a limited open reduction is necessary. It is done on a fracture table and subsequently, an appropriate fixation device is chosen. In most instances it will be an intramedullary device.

Note:
Only stable proximal femoral fractures can be treated with the DCS (dynamic condylar screw) plate. The DCS plate does not allow for controlled collapse and compression.

2 Reduction top

Reduction will be achieved by first pulling in the length axis of the leg in order to distract the fragments and regain length. enlarge

Closed reduction

The use of a traction table depends on the surgeon’s preference. In fresh cases, a traction table might not be necessary and the procedure can be done on a translucent table designed for use with image intensification.
If a traction table is used, the patient should be positioned as indicated in the drawing with his ipsilateral arm elevated in a sling while the contralateral uninjured leg is placed on a leg holder.
Reduction will be achieved by first pulling on the leg in order to distract the fragments and regain length. This should be controlled under image intensification.
The second step is internal rotation of the leg. Again it has to be checked under image intensification in 2 planes as the reduction determines the degree of internal rotation.


A pointed reduction clamp is placed while the distal femur is moved distally. enlarge

Open reduction

A straight 10 cm skin incision is made starting at the greater trochanter and carrying it downwards, parallel to the femoral axis. The fascia lata is incised in line with the skin incision and in line with its fibers. The vastus lateralis muscle is elevated from the intermuscular septum just enough to expose the fracture. To avoid bleeding, tie off the perforating vessels. If necessary use a small Hohmann in order to visualize the bone.
A pointed reduction clamp is used to reduce the fracture and maintain reduction.

3 Insertion of the dynamic condylar screw top

Technique of insertion

Lateral approach between the vastus lateralis muscle and intermuscular septum.


The aiming device is chosen according to the chosen CCD angle of the implant. enlarge

Application of the aiming device

The aiming device for the DCS is chosen. It is placed against the lateral cortex. Its position should be checked using image intensification in an AP view, according to the anticipated position of the guide wire.


The guide wire is inserted through the aiming device and should be in the caudal half of the femoral neck. enlarge

Insertion of a guide wire for the screw

The guide wire is inserted through the aiming device. In the AP view it should be in the lower or caudal half of the femoral head. On the axial view it should be parallel to the axis of the neck and in the middle of the neck. The guide wire is advanced into the subchondral bone and its tip should lie 10 mm off the joint.


Determine the length of the DCS screw with help of the measuring device. enlarge

Determination of the length of the DCS screw

Determine the length of the DCS screw with help of the measuring device. Select a screw which is the same length as measured.


Adjust the cannulated triple reamer to the chosen length of the screw. enlarge

Drilling

Adjust the cannulated triple reamer to the chosen length of the screw. Drill the hole for the screw and the plate sleeve.


The selected screw is mounted on a handle and inserted over the guide wire. enlarge

Screw insertion

The selected screw is mounted on a handle and inserted over the guide wire.
When the screw has reached its final position, the T-handle has to be in line with the longitudinal axis of the femur to guarantee that the plate will come to lie on the femoral shaft.
Remove handle and leave guide wire in place.

4 Fixation of the DCS plate top

An appropriate DCS plate has to be chosen, ensuring at least 8 cortical contacts of the holding screws in the distal fragment. enlarge

Application of the DCS plate

The length of the plate is determined by the extent of the fracture. One should aim to have at least five screw holes distal to the fracture since one needs eight cortices of screw purchase to ensure adequate fixation. In osteoporotic bone, five screws (10 cortices) are advised.
The DCS plate is now inserted and seated with the impactor. Compression of the fracture might be achieved if the cortical screws are inserted in a load position starting with the most distal screw. One might also use the articulated tension device if indicated. If the fracture pattern allows, additional cortical screws should be inserted into the proximal fragment to augment the fixation.


The plate is fixed to the femoral shaft with an appropriate number and size of plate holding cortical screws. enlarge

Insertion of holding screws

The plate is fixed to the femoral shaft with an appropriate number and size of plate holding cortical screws.
If possible insert lag screw(s) through the plate to compress the fracture.

v2.0 2010-11-14