K.-K. Dittel (cid:2) M. Rapp (cid:2) (Eds.) The Double Dynamic Martin Screw (DMS) Adjustable Implant System for Proximal and Distal Femur Fractures K.-K. Dittel M. Rapp (Eds.) The Double Dynamic Martin Screw (DMS) Adjustable Implant System for Proximal and Distal Femur Fractures In collaboration with W. Abendschein, A. Ateschrang, S. Decker-Burgard, M.-R. Felenda, K.K. Förster, D. Janssen, B. Marquardt, W. Miller, K.M. Peters, R. Plank, S. Uppenbrink, R. Zirn With 287 Figures in 400 separate Illustrations and 24 Tables (cid:2) (cid:3) Karl-Klaus Dittel, Prof. M.D. Matthias Rapp, M.D. Clinic of Orthopaedic Surgery, Traumatology and Reconstructive Surgery Marienhospital Stuttgart – Academic Hospital of the University of Tübingen, Germany Böheimstraße 37, D-70199 Stuttgart ISBN 978-3-7985-1841-4 Steinkopff Verlag BibliographicinformationpublishedbyDieDeutscheNationalbibliothek DieDeutscheBibliothekliststhispublicationintheDeutscheNationalbibliografie; detailedbibliographicdataisavailableintheInternetathttp://dnb.d-nb.de. This work is subject tocopyright.Allrightsarereserved,whether thewholeor partofthematerial is concerned, specifically therightsoftranslation,reprinting,reuseofillustrations,recitation,broadcasting,reproductiononmi- crofilmorinanyotherway,andstorageindatabanks.Duplicationofthispublicationorpartsthereofispermitted onlyunder theprovisions oftheGermanCopyrightLawofSeptember9, 1965, initscurrentversion,andpermis- sionforusemustalwaysbeobtainedfromSteinkopffVerlag.ViolationsareliableforprosecutionundertheGerman CopyrightLaw. SteinkopffVerlag amemberofSpringerScience+BusinessMedia www.steinkopff.com © SteinkopffVerlag2008 PrintedinGermany Theuseofgeneraldescriptivenames,registerednames,trademarks,etc.inthispublicationdoesnotimply,evenin the absence ofa specific statement, thatsuch names are exempt from the relevant protective laws and regulations andthereforefreeforgeneraluse. Productliability:Thepublisherscannotguaranteetheaccuracyofanyinformationabouttheapplicationofoperative techniquesandmedicationscontainedinthisbook.Inevery individualcasetheuser mustchecksuchinformation byconsultingtherelevantliterature. Medicaleditors:Dr.med.GertrudVolkert,PetraElster Production:KlemensSchwind Coverdesign:ErichKirchner,Heidelberg Typesetting:K+VFotosatzGmbH,Beerfelden Printingandbinding:StürtzGmbH,Würzburg SPIN12443000 105/7231–5 4 3 2 1 0–Printedonacid-freepaper Freedom of movement: Its value will be only recognized, when it is restricted Sir J. Charnley, 1957 Foreword The scope and importance of hip fractures is almost incomprehensible. With a world wide incidence of close to 2 million cases per year, these fractures pose a daunting challenge to our ability to affect and treat this epidemic. The incidence of these fractures is predicted to grow to 6 million in 2050 including a near term baby boom spike. Add the hospital mortality rate of up to 4% and the one mortality of from 8% to 20% and the life ending effect of these fractures becomes a glaring reality. Of those who initially survive their fracture, about 50% never walk the same again. The social problem in the care of these elderly people is enormous. Of course, any real solution to this problem will include education, prevention, surgical and hospital treatment protocols, long term rehabilitative efforts, social ad- justments and a generous contribution of money. This publication is primarily directed to the amplification of a new treatment modality that addresses only a fraction of the problem. It is, however, a quantum leap in the evolution of fixation with compression hip screws which are still the gold standard for surgical stabilization of pertrochanteric hip fractures. The Dynamic Martin Screw (DMS) addresses the issue of adjustability of the fixation angle with appropriate mechanical strength characteristics that were lack- ing in its historical predecessors. It exhibits the unique ability to allow the surgeon to improve the reduction to a more advantageous valgus angle even after it is rigidly attached to the femur. This provides a more stable construct that will allow for a more successful recovery of the patient to their previous ambulatory life. In addition, the device is ideally suited for a new challenge in hip fractures, the MRI fracture. These are undisplaced fractures diagnosed almost entirely by mag- netic resonance imaging. Since they are, by definition, undisplaced, the infinite ad- justment of the femur neck angle of this device is the perfect solution. The variable angle system has been adapted for paediatric use. While useful for fracture fixation, it is an excellent option for fixation in the varus femoral osteoto- my for dysplastic hips and subluxation in childrenwith cerebral palsy. Further on the supracondylar version is very valuable for distal femur fractures. The supracondylar version with cable extraordinarily is suited for the devastating periprosthetic femoral fracture in the total hip patient. This situation, by the way, is a new epidemic! Washington D.C., Summer 2008 Walter Abendschein, M.D. Preface Much has been written about changes in medicine – mankind has gone through – changes which influenced the development of medical speciality decisively and surely many more changes will continue to take place in coming years. Obviously only some of the advances in the treatment of fractures and degenera- tive diseases of the human motor system may be regarded as milestones in the de- velopment of orthopaedic and trauma related surgery. Major advances have been made specially in the treatment of femur fractures over the last five decades. There is no doubt that one milestone in the middle of the last century can be attributed to Ernst Pohl, a genious engineer from Kiel, who developed the first sliding device for osteosynthesis of hip fractures. He opened a new area in the field of conven- tional hip joint reconstruction, consequently embettering and developing an im- plant system, enabling the patient to walk with full weight bearing at an early time, reducing complications decisively and functional deficits to a minimum. Our book deals with trauma surgery at the hip joint and it includes all kinds of fractures from the femoral neck area as well as the intertrochanteric and the sub- trochanteric area. We know that there is no single method of treatment existing which could be used adequately for all type of fractures at the proximal femur. We believe on the other side that with the development of the DMS since 1993 and the experiences we have made personally with the new implant a spectrum of indica- tions for its implantation has been opened which is broader than the spectrum of many other implants which are used for fracture fixation at the hip. This does not mean that we belong to the type of surgeons who claim that one could use a single implant for all type of fractures. It is obvious that the better option is to use the best implant for an existing problem. We have made the attempt to give a tailor- made solution for treatment of joint localised fractures at the femur. Our experi- ence over 15 years show that a great number of problems can be solved with the DMS under the special aspect of its unique adjustability and anatomical congru- ence. Every year publications about fractures at the proximal femur present new bio- mechanically embettered or descripted ideal implants. Mostly ideal fractures with ideal results are presented by expelling the results about problems, complications and implant failures. That’s why we have included in the book several chapters which are dedicated to problem cases and pathological fractures for which the sur- gical management is controversially discussed until our days. The book finally includes chapters about perioperative antibiotic therapy, throm- bo-embolism prophylaxis, postoperative physiotherapy and osteoporosis manage- ment. We have written our book for colleagues who are working in trauma surgery and we hope that we have fulfilled the demands of objectivity. The reader should treat our attempt with leniency. Stuttgart, Summer 2008 Karl-Klaus Dittel Matthias Rapp Dedicated to my surgical teachers Ordinarius Prof. Dr. med. Wolfgang Schiefer Formerly Medical Director Neurosurgical University Clinic Erlangen ReproducedwithkindpermissionfromStadtarchivErlangen Prof. Dr. med. Friedrich Pampus Formerly Medical Director Neurosurgical Clinic Katharinenhospital Stuttgart ReproducedwithkindpermissionfromPressefotoKaufmann&Kaufmann, Stuttgart Prof. Dr. med. Erwin Kraft Formerly Medical Director Surgical Clinic Marienhospital Stuttgart ReproducedwithkindpermissionfromPublicRelationsOffice, MarienhospitalStuttgart Dedicated tomy surgical teachers (cid:2) XI Ordinarius Prof. Dr. med. Dr. med. h.c. mult. Siegfried Weller Formerly Medical Director BGU and University Clinic of Traumatology Tübingen In sincere gratitude The book is dedicated to Siegfried Weller at the occasion of his 80th birthday Karl-Klaus Dittel Acknowledgments In the front line we have to notice to be indebted to the authors of this book who have spent their precious time for preparing, revising, updating, writing and over- working their chapters. We are thankful for their work which they have done un- selfishly. They have prepared their contributions and manuscripts reliable in a very short time and we hope that our readers will give the attentiveness to their chapters they have earned. To the companies who have supported the printing we have to express our deep thank. Without their help the production of this book would not have been possi- ble. (cid:2) KLS Martin (cid:2) Pfizer (cid:2) Stryker (cid:2) Codon (cid:2) Carstens (cid:2) Aesculap (cid:2) Cardinal Health – Thanks for their support in form of a contribution to the print costs. – Thanks for the support in form of an advertisement. – Thanks for the support concerning the necessary illustrations (Mrs. Rose Baumann) which had to be drawn for the book. (cid:2) Thanks to the Steinkopff Verlag crew (Mrs. Dr. med. Gertrud Volkert, Mrs. Petra Elster, Mr. Klemens Schwind) for their important advices and comments which influenced the outcome of the book positively. (cid:2) Thanks to our secretary Mrs. Reim who showed no tiredness in writing the texts repeatedly. (cid:2) Thanks to our colleagues who have stimulated us continuously with their ideas and mental contributions to do our very best by publishing. (cid:2) Thanks to the colleagues and friends Bud Abendschein, M.D., Washington D.C. USA and Don Lyddon, M.D., Rockford USA who did a thoroughly job by trans- lating some of the german texts into english. We are very lucky that the printing of the book was possible based on an effective and trustworthy collaboration with all involved persons who have enabled the com- pletion in time. Karl-Klaus Dittel Matthias Rapp