An Operative Manual of Proximal Femoral Fractures Dhananjay Gupta , Sumit Banerjee
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1An Operative Manual of Proximal Femoral Fractures2
3An Operative Manual of Proximal Femoral Fractures
Editors Dhananjay Gupta DNB Orth D Orth Fellow AO, Senior Consultant, Orthopedics Hip and Knee Reconstruction and Replacement Surgeon, Fortis Flt Lt Rajan Dhall Hospital New Delhi, India Sumit Banerjee MBBS MS MCh (ORTHO) Fellowship in Sports Injury and Orthopedics Stuttgart, Germany Clinical Fellow in Reconstructive Knee Surgery, Darlington Memorial Hospital, Durham, UK Forewords Lawrence D Dorr Surya Bhan
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An Operative Manual of Proximal Femoral Fractures
First Edition: 2016
9789351524854
Printed at
5Dedicated to
God almighty who has been very kind to me, guiding me towards my destiny. My Parents,
Manorama and Jitendra along with my brothers Sanjay and Mrityunjay who pampered the
youngest one in the family with love and care
Wife Ila, for putting up with “working from home”, and my kids Pranav and Pranita, who put
up with my “busy with book” refrain.
My teachers, mentors and guides in Gwalior, Pune, Mumbai and Delhi.
Dhananjay Gupta
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7CONTRIBUTORS
9FOREWORD
The proximal femur is the geometric structural support of the hip joint. The hip joint is the center of the body. It links the proximal trunk to the legs below. It is the principal joint of the body. Therefore, when it is injured, the future mobility and productivity of the patient is threatened. If the injury is not expertly treated, the patient will live with discomfort the remainder of his/her life
An Operative Manual of Proximal Femoral Fractures is very important for the orthopedic surgeons to understand these reasons, no matter the stage of their career. Young or old, the current best methods of repair of injury of the proximal femur is knowledge that must be known. For the young surgeons, this knowledge can mold your approach to these fractures; for the experienced surgeons, this knowledge can provide techniques that allow you to modify your treatment for more predictable outcomes. The editors are to be commended for sacrificing their personal time to prepare the book.
I am particularly pleased of the emphasis on use of total hip replacement for femoral neck fractures. I first researched this option over 20 years ago. This is an underutilized operative treatment for patients who suffer this injury. A hemiarthroplasty is a “knee jerk” response by orthopedic surgeons, particularly for patients 65 years of age and older. For this age group of patients, whose activity is either a household ambulator, or limited community ambulator (two blocks), a hemiarthroplasty is the correct decision. For this age group of patients, who walk distances, or are unlimited in their activity, only total hip replacement will make them pain free. Too often the surgeon does not adequately question the patient, or the patient's family, to learn the activity status of the patient before operating.
Fracture care is the foundation of the orthopedic surgeon. It is our history, and our future. Even with reconstructive surgery such as total hip replacement (THR), we surgeons fracture the bone with controlled methods to repair its disease. So young surgeons must embrace the knowledge of fracture care taught in the book. Without a true understanding of the principles of fracture repair/healing, an orthopedic surgeon never knows his/her profession.
To continually experience the Thrill of Victory as a surgeon, we must be a great surgeon. To be great means highly educated, and your skills refined by experience. Experience is not so much number of cases, or years or practice, but is the repetition of the same skill until superbly refined. So, embrace the technique you choose from the options presented in the book, and use it again and again until it is second nature to you and give thanks to the editors who took the time to educate you by the book. I personally commend them.
Lawrence D Dorr MD
Professor
Department of Orthopedics
University of Southern California Medical School
Los Angeles, California, USA
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11FOREWORD
It is my pleasure to write foreword for An Operative Manual of Proximal Femoral Fractures edited by Dr Dhananjay Gupta on proximal femur fractures. Dr Dhananjay Gupta and Dr Sumit Banerjee have put together a good compendium for the readers. Different chapters have been written by different contributors who have good experience and have put in great effort to give excellent knowledge and in-depth perspective.
Proximal femur fractures, which include fractures of femoral head, neck, intertrochanteric and subtrochanteric regions, have always been challenging not only because of their varied patterns but also because the treatment varies with age and require early mobilization with full weight bearing. However, osteoporosis in this patient population makes sound and stable internal fixation difficult, and hence arthroplasty takes a leading role. Though the role of arthroplasty is clear in fractures of femoral neck in elderly, it is still debated for intertrochanteric fractures. In contrast, every effort should be made in young patients to preserve the natural anatomy. Early anatomical reduction and surgical fixation remains the best option to reduce the risk of complications
Chapters on Operative Techniques in difficult and rare fractures such as femoral head fractures and subtrochanteric fractures will be beneficial for young surgeons. Editors have also discussed the role of hip replacement in femoral neck fracture which will help readers to decide best replacement modality for their elderly patients. Chapter on Prosthetic Replacement in Comminuted Intertrochanteric Fractures will make orthopedic surgeons to keep this option in back of their minds as very elderly patients can be rapidly mobilized following replacement, decreasing morbidity and mortality associated with these fractures. Chapters on Periprosthetic Fractures and Pathological Fractures make the book complete as these are not only most difficult of the lot but also increasing in day-to-day practice.
I am sure that the book will be helpful for its readers, not only to improve their techniques and outcomes but also to resolve some of the controversies surrounding management of proximal femoral fractures. Ultimately, it will be the patient who will benefit the most. I wish best of luck to the editors for the success of the book.
Surya Bhan MS FRCS FAMS
Director
Department of Orthopedics
Primus Super Speciality Hospital
New Delhi
Former Head
Department of Orthopedics
All India Institute of Medical Sciences
New Delhi, India
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13PREFACE
Hip joint and proximal femur has always been a challenging region due to complex and varied anatomy with powerful muscular forces. Principles and modalities of treatment are still evolving in the attempt to mobilize the patients early. When I was undergoing postgraduate training, we were treating all proximal femoral fractures conservatively except for neck fractures. In young patients, cancellous screws under X-ray control and Austin-Moore Prosthesis in elderly. Intertrochanteric fractures were treated with skeletal traction in suspended T-splints on Balkan beams, with serial bedside X-rays. Subsequently, witnessed the revolution brought about by image intensifier and gradual loss of art of close reduction. Subsequently, journey from fixed angle devices to dynamic hip screw (DHS), proximal femoral nail (PFN), proximal femoral locking plates (PFLPs) and challenging arthroplasties has been quite enlightening. This exposure to whole spectrum of treatment modalities, having seen all types of result—good and bad, prompted me to come out with one such book.
Perhaps it is difficult to breakdown the surgical philosophy into steps and prepare a manual as all surgeons eventually find their own way around. As Professor NS Laud used to say, There are three answers to a problem or situation—yours, mine and right one. Our endeavor hopefully helps in tiding over this experience seeking phase till you have gained enough wisdom to start sharing it. There has been an effort to give a basic detail about the region or pathology concerned, and then give a detailed step-by-step surgical procedures with tips and pearls. Some authors have been very detailed while some chose to discuss the philosophy behind the surgical procedures with useful tips. We are sure you will find something or other useful in this book.
The book is primarily meant for the residents and young orthopedic surgeons. If they can refer to these in their first 25 cases, they can lay down a good foundation for themselves. An attempt has been made to create a thought process in the mind of the readers about the topic, navigate them through the steps of surgical procedures.
Initially, we wanted to keep the book restricted to the fracture fixation techniques. But realized it may limit the scope of the book as arthroplasty methods have greatly advanced. At times, it may be justified to replace rather than preserve and subject the patient to prolonged rehabilitation and uncertain outcome.
We shall appreciate your feedback so that we can improve our subsequent editions.
We are planning to come with subsequent edition to this work. It will have a detailed description and analysis of all possible complications associated with proximal femoral fractures. This is going to be a herculean task, and yet we are hopeful to get this to you shortly.
Dhananjay Gupta
Sumit Banerjee
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15ACKNOWLEDGMENTS
All the contributors who took time out of their busy routine to provide the chapters. Many of them had to work on holidays to get the required pictures. I am eternally grateful to all of them.
Dr Sumit Banerjee who managed to put the things in clear perspective with his superior intelligence and clear thinking. Dr Anmol Maria and Dr Ashutosh Agarwal have been a pillar of strength with their unflinching support.
Dr Vipul Khera, Dr Sunil Malhotra, Dr Anchit Uppal, Dr Usman Khan and Dr Bipul Singh put in their valuable inputs from time-to-time. Dr Surya Prakash helped in preparation of manuscript.
My colleagues in hospitals, and Delhi Orthopedic Association who never refrained from giving their valuable and critical opinions.
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