Implant specific complications, pitfalls, tips and tricks with PFN-A

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Implant specific complications, pitfalls, tips and tricks with PFN-A
Is the
biomechanical
problem of
trochanteric
fracture solved?
Dr Gabor Szabo
Josa Andras Teaching Hospital
Nyíregyhaza, Hungary
Naumov et al:
Per and subtrochanteric fractures
Magyar Traumatológia, Ortopédia, Kézsebészet,Plasztikai Sebészet, 2002. 45. 1.
local complications (n=316) 6,4%
I. B. Schipper et al:
Randomised comparison of the gamma nail and the proximal femoral nail
The Journal of Bone and Joint Surgery, 2004;86-B: 86-94.
mechanical complications : PFN (n=221): 57 (25%)
gamma-nail (n=213): 53 (24,8%)
postoperative complications: PFN: 31 (14%)
gamma-nail: 20 (9,4%)
Badó et al:
Experiences with Gamma nailing
Magyar Traumatológia, Ortopédia, Kézsebészet, Plasztikai Sebészet, 2008. 51. 2.
local complications (n=621): 6,7% (short nail)
S. Pietruschka et al:
Erfahrungen mit dem Gamma-Nagel
Einfluss des Verzichtes auf die distale Markraumerweiterung
mechanical complications (intraoperativ): 15%
postoperative complications: 5,9%
605 proximal femoral fractures
(2005-2008)
PFN-A
other proximal
femoral nail
111 (18,4%)
494 (81,6%)
15%
24%
38%
29%
47%
47%
A1
A2
A3
A1
A2
A3
180
158
160
166
No. of cases
140
120
100
80
64
56
60
42
40
20
2 0
2 4
5 4
14
6
8
28 25
16
3
0
<20 év 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100
év
év
év
év
év
év
Patients
ages
(year)
PFN-A
PFN-A
év
év
20
100
év<
egyéb
Othertrochanter-szeg
nail
Intraoperativ complications (n=605)
problems with the
inserter’s removal
distal lockin failure
Intraoperativ fractures
reposition failure (varus)
PFN-A (n=494)
other nail (n=111)
1 (0,2%)
1 (0,2%)
1 (0,2%)
7 (1,4%)
0
3 (2,7%)
1 (0,9%)
2 (1,8%)
Postoperativ mechanical complications
cut out of the head
distal cut out and fracture
head perforation
distal screw slide out
distal screw break
nail break
slide out of the component
from the head
periimplantatoric fracture
reoperation because
mechanical problems
2 (0,4%)
0
0
1 (0,2%)
0
0
1 (0,9%)
1 (0,9%)
1 (0,9%)
0
1 (0,9%)
1 (0,9%)
1 (0,2%)
6 (1,2%)
0
1 (0,9%)
4 (0,8%)
2 (1,8%)
Implant specific
complications
PFN-A
other nail
(n=494)
(n=111)
intraoperativ
postoperativ
3 (0,6%)
8 (1,6%)
4 (3,6%)
7 (6,3%)
summ
11 (2,2%)
11 (9,9%)
Why do we like?
Reduced the complication rate to
20% (from 9,9% to 2,2%) in our
department
Precise instruments (easy and
fast technique)
Reliable stability in osteoporotic
and unsable cases
Minimally invasive
What is the secret?
The antirotation blade
Anatomical design
Dinamic fixation between
nail and blade
Flexible nail tip
Implant specific
complications,
case reports, tips
and tricks
with
PFN-A
Dr Gabor Szabo
Josa Andras Teaching Hospital
Nyíregyhaza, Hungary
1. 23 y.o. polytrauma patient
2007.
08.
11.
2007.
11.
02.
2009.10.02
postop.
Comminuted shaft frecture with PFN-A, after 3 months good
callus formation, no dislocation, full weight bearing.
After 2 years: IMPLANT REMOVAL???
2. 67 y.o. male pertrochanteric
fracture with healed PFN-A
For adekvate trauma shaft fracture
under. Threated with PFN-A long
and healed after dinamization.
3. 82 y.o. female
pathological fracture
(pulm. cc. metast.)
with PFN-A.
4. Reposition failure
(varus) &
implant malposition
Patient positioning
Reduce the
fracture
Determine the inserion
point well!
Avoid the forced
internal rotation!
5. Malposition of the blade 1.
spongiosa
impactation
2006.04.30.
2006.06.08.
2006.06.12.
2006.09.01.
Antero-central position of the blade with poor bone quality.
Cranial migration of blade and cut out.
Healing after reoperation with PFN-A and spongiosa impactation.
With good bone quality and no severe insatbility
= CENTRAL POSITIONED BLADE
Poor bone quality and/or
severe insatbility =
POSITION IN 6-8-9
„CLEVELAND” ZONE
(postero-inferior)
???
The rotation force increases
with excentral placed blade!
Central blade position
+
No drilling for the blade, only open
the lateral cortex
6. Malposition of the blade 2.
2006.02.11.
2006.04.01.
2006.08.08.
The blade is subchondral, good bone healing with no
femoral head perforation
7. The sipral blade’s nut had to be broken down with the inserter
because they stucked together.
3 weeks after the moved away sleeve was extracted, the fracture
healed in varus position.
Untighten all and in fully locked position the
inserter will be able to taken over
8. The
screwdriver’s tip
can be broken
into the endcup.
After the synthesis is stabil, more
space available at the trochanteric
region if you adducate the hip
Canulated technique
is not necessary
9. The tip of the drill bit broke into the bone
Alwalys check the tighten
before distal locking!
Change the sleeves
(dynamic static) and it will
lead your new drill bit
belongside the broken piece,
so after this you will be
able to pick it
10. Lateral femoral neck fracture with PFN-A
GOOD or BAD INDICATION???
Thank you for
your attention!

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