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Image intensifier as an aid to insertion of the Zickel nail apparatus for proximal femoral fractures
148
Injury, 11. 1 4 8 - 1 5 4
Printed in Great Britain
Image intensifier as an aid to insertion of the Zickel nail apparatus for proximal femoral fractures I. W. Forster Senior Orthopaedic Registrar, Harlow Wood Orthopaedic Hospital J. A. Lindsay Orthopaedic Registrar, Derbyshire Royal Infirmary
Summary
(Fig. 1). Mickelson and Bonflglio (1976) altered
Technical problems have been encountered when using the usual method of implanting the Zickel nail. We have attempted to overcome them by placing the patient on an orthopaedic table and screening the femur using an image intensifier. The results, and the particular ways in which this technique has helped, are described.
their technique by placing their patients in the lateral position in order to make it easier to take satisfactory radiographs. We performed our first operation using Zickel's technique, but found it difficult to take the radiographs of the femoral neck. Accordingly, we decided to use the image intensifier (Phillips BV 20S) which is currently in use for all other hip fractures. The intensifier is a standard unit comprising a C-arm and control panel attached to a television monitoring screen.
INTRODUCTION
THE Zickel nail apparatus is becoming established as a method of internal fixation of proximal femoral fractures (Mickelson and Bonfiglio, 1976; Zickel, 1976; Zickel and Mouradian, 1976). Zickel (1976) described his technique in which the patient was placed supine on the ordinary operating table with a bolster under the affected hip. The desired position of the tri-flanged nail within the neck was judged by placing a finger and thumb on either side of the femoral neck and aligning it with the jig made for passing the guide wire, which was attached to the femoral rod as it was inserted. Zickel also used radiological control (Fielding et al., 1974). Most surgeons in this country have used this method. There have been reports of the triflanged nail passing outside the femoral neck (Cross and Murphy, 1977) and a few cases in another centre of the rod going outside the femoral shaft through a lower comminution
PATIENTS AND METHODS
The patient is placed supine on the Hawley orthopaedic table. Both legs are strapped to the foot pieces and placed in traction so that the pelvis is approximately level. The leg is placed in the correct plane of rotation for reduction. The sound leg is then abducted as far as possible and the fractured limb is adducted strongly (Fig. 2). The image intensifier is located between the legs initially and covered by drapes so that it can be moved into position for screening without unduly disturbing the sterile field. The fracture is then approached via a lateral incision and the fascia lata divided longitudinally. Vastus lateralis is stripped forward from its posterior attachments and the fracture site is identified. It is important to display the
Forster and Lindsay: Zickel Nail Insertion
149
Fig. 2. Initial position of the image intensifier with leg strongly adducted. Fig. 1. Zickel nail penetrating the femoral cortex through an unsuspected comminution of the fracture.
a
b
Fig. 3. Image intensifier position for hip screening in (a) anteroposterior and (b) lateral planes. entire fracture. After clearing the bone ends of soft tissue, the distal shaft is reamed to its maximal diameter, the appropriate rod selected and tried for size. The tip of the greater trochanter is excised and a hole large enough to take the 17-ram reamer is gouged out of it. The proximal fragment is reamed from above, the fracture reduced and the Zickel nail passed in the normal fashion, taking care to align the jig as accurately as possible with the centre of
the femoral neck. This is done using the manoeuvre described by Zickel (! 976), the neck in this position usually being slightly anteverted. Having checked the position of the rod in the femoral shaft under the image intensifier, the operated leg is abducted and the intensifier positioned to screen the hip in the anteroposterior and lateral planes (Figs. 3a and b). The guide wire is passed through the jig and femoral cortex into the neck and its position accurately
50
Injury: the British Journal of Accident Surgery Vol. 11/No. 2
Fig. 4. a, Pathological fracture of proximal third ofthe femur, b, Fixation with Zickel nail in anteroposterior plane, c, Fixation with Zickel nail in lateral plane.
determined by means of the image intensifier. The operation then proceeds in the manner described by Zickel (1976). RESULTS The Zickel apparatus has been used by the authors ten times without any technical problems. The ages and indications for
operation are outlined in Table L Four of the patients (no. 1, 3, 6 and 9) had gross involvement of the whole proximal femur by tumour with fractures at the subtrochanteric level (Fig. 4a). One patient (no. 3) had virtually no bone in the greater trochanter at the site of the femoral rod because of a metastasis. Nevertheless, satisfactory fixation and position of the implant were achieved (Figs. 4b and c). Another
Forster and Lindsay:Zickel Nail Insertion
151
Table I. Review of patients with Zickel nail implants
Sex
Age (yr)
1
F
55
Pathological subtrochanteric fracture of the femur
2
M
20
3
F
63
RTA subtrochanteric and mid-shaft fractures of the femur Pathological subtrochanteric fracture with metastasis to mid-shaft level
4
F
75
5
F
75
6
F
65
7
F
73
8
M
75
9
F
45
Pathological subtrochanteric fracture of the femur
10
M
78
Spiral fracture of proximal third of the femur
No.
Indication
Results
Intertrochanteric fracture with spiral extension down shaft Mechanical failure of original pin/plate for subtrochanteric fracture Pathological subtrochanteric fracture with metastases to mid-shaft level Comminuted sub- and intertrochanteric fracture Comminuted sub- and inte~rochanteric fracture
patient (no. 5) had a subtrochanteric fracture stabilized by a sliding pin and twelve-hole plate (Figs. 5a and b). The patient developed nonunion and late varus deformity (Fig. 5c). The metal was removed and replaced by a Zickel nail in conjunction with a Phemister bone graft (Fig. 5d). The fracture has now united in an excellent position. DISCUSSION The image intensifier has allowed us to be sure of the position of the tri-flanged nail within the head of the femur, which is most important when at least part of the fracture is across the base of the femoral neck. With this technique it is possible to hold extracapsular femoral neck fractures as securely as with a standard pin and
Good fixation. Death at 10 days with multiple metastases Union in anatomical position with full joint function at 3 months Good fixation initially but tri-flanged nail cut out at 4 weeks. Death at 2 months from metastases Union in anatomical position at 6 months. Full recovery Union in excellent position at 3 months. Full recovery Good fixation. Patient left hospital with partial weight bearing 2 weeks after radiotherapy Good fixation Satisfactory fixation though degree of comminution would not allow weight immediately after operation. Got up after 6 weeks' traction Trochanter split at operation. Got up in cast brace splint with waist band Out of bed after operation. Progressing satisfactorily at 2 months
plate (patients no. 4 and 7) (Figs. 6a-d). These fractures may be complicated by a fracture of the femoral shaft (patient no. 2) or may actually extend into the shaft (patients no. 4, 8 and 10). It is useful to be able to screen the femoral shaft at operation to ensure that the rod has not come out of the cortex through a hitherto unsuspected element of the fracture (Fig. l) or through a metastasis further down the shaft. The image intensifier allows screening of the lower end of the rod to see if this approaches the knee (patient no. 6). Zickel (1976) commented that he had to shorten his nail to fit one of his patients who was particularly short. It seems that this is an easier technique than that currently described. The authors have experienced no technical complications and strongly advise its use.
52
Injury: the British Journal of Accident Surgery Vol. 11/No. 2
a
c
b
d
Fig. 5. a, Comminuted subtrochanteric fracture, b, Initial fixation with sliding nail and plate, c, Varus deformity
with non-union, d, Bone grafts and Zickel nail followed by union.
Forster and Lindsay: Zickel Nail Insertion
153
a
b
c
d
Fig. 6. a, Comminuted inter- and subtrochanteric fracture, b, Fixation with Zickel nail and cerclage wires, c, Union without displacement in anteroposterior plane, d, Union without displacement in lateral plane.
154
Injury: the British Journal of Accident Surgery Vol. 11/No. 2
Acknowledgements
Miekelson M. R. and Bonfiglio M. (1976) Pathological fractures in the proximal part ofthe femur treated by Zickel nail fixation. J. Bone Joint Surg. 58A, 1067. Zickel R. E. (1976) An intramedullary fixation device for the proximal part of the femur: nine years' experience. J. Bone Joint Surg. 58A, 866. Zickel R. E. and Mouradian W. H. (1976) Intramedullary fixation of pathological fractures and lesions of the subtrochanteric region of the femur. J. Bone Joint Surg. 58A, 1061.
We would like to thank Mr G. Newton and Mr A. P. J. Henry, consultant orthopaedic surgeons at the Derbyshire Royal Infirmary, for allowing us to review their patients. REFERENCES
Cross A. T. and Murphy W. M. (1977) Subtrochanteric fractures and the Zickel apparatus. J. Bone Joint Surg. 59B, 498. Fielding J. W., Cochran G. V. B. and Zickel R. E. (1974) Biomechanical characteristics of surgical management of subtrochanteric fractures. Orthop. Clin. North Am. 5, 629.
Requests for reprints should be addressed to: Mr I. W. Forster, Senior Orthopaedic Registrar, Harlow Wood Orthopaedic Hospital, Mansfield,Nottinghamshire.
Injury, 11. 1 4 8 - 1 5 4
Printed in Great Britain
Image intensifier as an aid to insertion of the Zickel nail apparatus for proximal femoral fractures I. W. Forster Senior Orthopaedic Registrar, Harlow Wood Orthopaedic Hospital J. A. Lindsay Orthopaedic Registrar, Derbyshire Royal Infirmary
Summary
(Fig. 1). Mickelson and Bonflglio (1976) altered
Technical problems have been encountered when using the usual method of implanting the Zickel nail. We have attempted to overcome them by placing the patient on an orthopaedic table and screening the femur using an image intensifier. The results, and the particular ways in which this technique has helped, are described.
their technique by placing their patients in the lateral position in order to make it easier to take satisfactory radiographs. We performed our first operation using Zickel's technique, but found it difficult to take the radiographs of the femoral neck. Accordingly, we decided to use the image intensifier (Phillips BV 20S) which is currently in use for all other hip fractures. The intensifier is a standard unit comprising a C-arm and control panel attached to a television monitoring screen.
INTRODUCTION
THE Zickel nail apparatus is becoming established as a method of internal fixation of proximal femoral fractures (Mickelson and Bonfiglio, 1976; Zickel, 1976; Zickel and Mouradian, 1976). Zickel (1976) described his technique in which the patient was placed supine on the ordinary operating table with a bolster under the affected hip. The desired position of the tri-flanged nail within the neck was judged by placing a finger and thumb on either side of the femoral neck and aligning it with the jig made for passing the guide wire, which was attached to the femoral rod as it was inserted. Zickel also used radiological control (Fielding et al., 1974). Most surgeons in this country have used this method. There have been reports of the triflanged nail passing outside the femoral neck (Cross and Murphy, 1977) and a few cases in another centre of the rod going outside the femoral shaft through a lower comminution
PATIENTS AND METHODS
The patient is placed supine on the Hawley orthopaedic table. Both legs are strapped to the foot pieces and placed in traction so that the pelvis is approximately level. The leg is placed in the correct plane of rotation for reduction. The sound leg is then abducted as far as possible and the fractured limb is adducted strongly (Fig. 2). The image intensifier is located between the legs initially and covered by drapes so that it can be moved into position for screening without unduly disturbing the sterile field. The fracture is then approached via a lateral incision and the fascia lata divided longitudinally. Vastus lateralis is stripped forward from its posterior attachments and the fracture site is identified. It is important to display the
Forster and Lindsay: Zickel Nail Insertion
149
Fig. 2. Initial position of the image intensifier with leg strongly adducted. Fig. 1. Zickel nail penetrating the femoral cortex through an unsuspected comminution of the fracture.
a
b
Fig. 3. Image intensifier position for hip screening in (a) anteroposterior and (b) lateral planes. entire fracture. After clearing the bone ends of soft tissue, the distal shaft is reamed to its maximal diameter, the appropriate rod selected and tried for size. The tip of the greater trochanter is excised and a hole large enough to take the 17-ram reamer is gouged out of it. The proximal fragment is reamed from above, the fracture reduced and the Zickel nail passed in the normal fashion, taking care to align the jig as accurately as possible with the centre of
the femoral neck. This is done using the manoeuvre described by Zickel (! 976), the neck in this position usually being slightly anteverted. Having checked the position of the rod in the femoral shaft under the image intensifier, the operated leg is abducted and the intensifier positioned to screen the hip in the anteroposterior and lateral planes (Figs. 3a and b). The guide wire is passed through the jig and femoral cortex into the neck and its position accurately
50
Injury: the British Journal of Accident Surgery Vol. 11/No. 2
Fig. 4. a, Pathological fracture of proximal third ofthe femur, b, Fixation with Zickel nail in anteroposterior plane, c, Fixation with Zickel nail in lateral plane.
determined by means of the image intensifier. The operation then proceeds in the manner described by Zickel (1976). RESULTS The Zickel apparatus has been used by the authors ten times without any technical problems. The ages and indications for
operation are outlined in Table L Four of the patients (no. 1, 3, 6 and 9) had gross involvement of the whole proximal femur by tumour with fractures at the subtrochanteric level (Fig. 4a). One patient (no. 3) had virtually no bone in the greater trochanter at the site of the femoral rod because of a metastasis. Nevertheless, satisfactory fixation and position of the implant were achieved (Figs. 4b and c). Another
Forster and Lindsay:Zickel Nail Insertion
151
Table I. Review of patients with Zickel nail implants
Sex
Age (yr)
1
F
55
Pathological subtrochanteric fracture of the femur
2
M
20
3
F
63
RTA subtrochanteric and mid-shaft fractures of the femur Pathological subtrochanteric fracture with metastasis to mid-shaft level
4
F
75
5
F
75
6
F
65
7
F
73
8
M
75
9
F
45
Pathological subtrochanteric fracture of the femur
10
M
78
Spiral fracture of proximal third of the femur
No.
Indication
Results
Intertrochanteric fracture with spiral extension down shaft Mechanical failure of original pin/plate for subtrochanteric fracture Pathological subtrochanteric fracture with metastases to mid-shaft level Comminuted sub- and intertrochanteric fracture Comminuted sub- and inte~rochanteric fracture
patient (no. 5) had a subtrochanteric fracture stabilized by a sliding pin and twelve-hole plate (Figs. 5a and b). The patient developed nonunion and late varus deformity (Fig. 5c). The metal was removed and replaced by a Zickel nail in conjunction with a Phemister bone graft (Fig. 5d). The fracture has now united in an excellent position. DISCUSSION The image intensifier has allowed us to be sure of the position of the tri-flanged nail within the head of the femur, which is most important when at least part of the fracture is across the base of the femoral neck. With this technique it is possible to hold extracapsular femoral neck fractures as securely as with a standard pin and
Good fixation. Death at 10 days with multiple metastases Union in anatomical position with full joint function at 3 months Good fixation initially but tri-flanged nail cut out at 4 weeks. Death at 2 months from metastases Union in anatomical position at 6 months. Full recovery Union in excellent position at 3 months. Full recovery Good fixation. Patient left hospital with partial weight bearing 2 weeks after radiotherapy Good fixation Satisfactory fixation though degree of comminution would not allow weight immediately after operation. Got up after 6 weeks' traction Trochanter split at operation. Got up in cast brace splint with waist band Out of bed after operation. Progressing satisfactorily at 2 months
plate (patients no. 4 and 7) (Figs. 6a-d). These fractures may be complicated by a fracture of the femoral shaft (patient no. 2) or may actually extend into the shaft (patients no. 4, 8 and 10). It is useful to be able to screen the femoral shaft at operation to ensure that the rod has not come out of the cortex through a hitherto unsuspected element of the fracture (Fig. l) or through a metastasis further down the shaft. The image intensifier allows screening of the lower end of the rod to see if this approaches the knee (patient no. 6). Zickel (1976) commented that he had to shorten his nail to fit one of his patients who was particularly short. It seems that this is an easier technique than that currently described. The authors have experienced no technical complications and strongly advise its use.
52
Injury: the British Journal of Accident Surgery Vol. 11/No. 2
a
c
b
d
Fig. 5. a, Comminuted subtrochanteric fracture, b, Initial fixation with sliding nail and plate, c, Varus deformity
with non-union, d, Bone grafts and Zickel nail followed by union.
Forster and Lindsay: Zickel Nail Insertion
153
a
b
c
d
Fig. 6. a, Comminuted inter- and subtrochanteric fracture, b, Fixation with Zickel nail and cerclage wires, c, Union without displacement in anteroposterior plane, d, Union without displacement in lateral plane.
154
Injury: the British Journal of Accident Surgery Vol. 11/No. 2
Acknowledgements
Miekelson M. R. and Bonfiglio M. (1976) Pathological fractures in the proximal part ofthe femur treated by Zickel nail fixation. J. Bone Joint Surg. 58A, 1067. Zickel R. E. (1976) An intramedullary fixation device for the proximal part of the femur: nine years' experience. J. Bone Joint Surg. 58A, 866. Zickel R. E. and Mouradian W. H. (1976) Intramedullary fixation of pathological fractures and lesions of the subtrochanteric region of the femur. J. Bone Joint Surg. 58A, 1061.
We would like to thank Mr G. Newton and Mr A. P. J. Henry, consultant orthopaedic surgeons at the Derbyshire Royal Infirmary, for allowing us to review their patients. REFERENCES
Cross A. T. and Murphy W. M. (1977) Subtrochanteric fractures and the Zickel apparatus. J. Bone Joint Surg. 59B, 498. Fielding J. W., Cochran G. V. B. and Zickel R. E. (1974) Biomechanical characteristics of surgical management of subtrochanteric fractures. Orthop. Clin. North Am. 5, 629.
Requests for reprints should be addressed to: Mr I. W. Forster, Senior Orthopaedic Registrar, Harlow Wood Orthopaedic Hospital, Mansfield,Nottinghamshire.