- Email: [email protected]
IMHS clinical experience in the treatment of peritrochanteric fractures
Injury, Int. J. Care Injured 33 (2002) 407–412
IMHS clinical experience in the treatment of peritrochanteric fractures The results of a multicentric Italian study of 981 cases E. Rebuzzi a,∗ , A. Pannone a , S. Schiavetti a , P. Santoriello a , U. de Nicola a , G. Fancellu b , P. Cau b , S. Gulli b , P. Dordolin b , P. Maniscalco c , F. Morici d , M. Commessatti d , M. Pozzi-Mucelli e , C.S. Maiorana e , F. Bassini e a
e
Department of Orthopaedics, Treviso, Italy b University of Trieste, Trieste, Italy c University of Siena, Siena, Italy d VI Division Orthopaedic Institute Rizzoli, Bologna, Italy Operative Unity of Orthopaedics, A.S.S.N. 3, Alto Friuli, Italy Accepted 27 March 2002
Abstract This retrospective study evaluates the results obtained in five Italian departments of traumatology in the treatment of peritrochanteric (pertrochanteric and subtrochanteric) fractures by the intramedullary hip screw (IMHS; Smith & Nephew Richards, Memphis, TN, USA) nail. One thousand two hundred and seventy-three patients were treated with the IMHS nail between March 1992 and February 2000. The results of these operations were evaluated clinically and radiological in 981 patients. The 90.3% of patients could walk unaided or with simple support. Because of the low complication rate requiring re-operation (postoperative shaft fractures, screw penetrated the acetabulum, cut out and non-union) (1.7%), we think that this device is an advance in the treatment of peritrochanteric fractures. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction Surgical treatment of peritrochanteric fractures has evolved during the last 40 years. The early rigid nail-plate devices did not allow fracture impaction. This caused mechanical complications when an unstable fracture collapsed into a more stable position. Later in the 1960s, displacement osteotomies were developed to convert unstable to stable fractures [7,23]. Unfortunately, mechanical problems of additional impaction persisted [16]. In the 1970s, sliding nail and screw devices became popular. These devices are load sharing and allow early mobilisation and weight bearing without the risk of fixation failure, typical of the load bearing rigid nail-plate devices [14]. Intramedullary fixation with the Ender nail was also used. The advantage of this technique was a minimal surgical approach with low blood loss, but several complications were reported. Jensen and Sonne-Holm [13] reported a 46% re-operations rate in unsta∗
Corresponding author. Present address: Via Garibaldi 73, 33080 Cecchini di Pasiano, Pordenone, Italy. Tel.: +43-0422-715329; fax: +43-0422-715401. E-mail address: [email protected] (E. Rebuzzi).
ble fractures treated by Ender nailing. Nowadays, the most commonly used methods are various types of screw-plates or interlocking nails. The interlocking nails are designed to apply the principles of locked intramedullary nailing and lag screw fixation in the treatment of peritrochanteric and high subtrochanteric fractures. Theoretically, the use of an intramedullary device should decrease the bending lever arm and torsion force, resulting in less implant stress [14,20]. Reported complications of interlocking nailing include poor positioning of the screw in the head, secondary dislocation of the fracture during the insertion of the nail, cut out, thigh discomfort, tip impingement and fractures of the femoral shaft. These may be caused by errors of indication, implant design, iatrogenic or induced errors of technique during the learning curve [4,17,20,26]. The IMHS was developed to overcome these problems [3,12,21]. 2. Materials and methods The five centres were given a form for clinical and radiographic evaluation (type of fracture, sex and age, preoperative and final ability to walk, surgical technique, time of consolidation, intra- and postoperative complications).
0020-1383/02/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 0 7 0 - 0
408
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
Table 1 Preoperative data of the 981 patients with peritrochanteric femoral fractures Mean age in years (range): 80.77 (36–104) Male/females: 1:4 Side of fracture (l:r): l = r Fracture pattern (Kyle–Gustilo) type: I (451), II (250), III (179), IV (101) Pathological fractures: 10 Non-union: 1 Bifocal: 1 Preoperative mobility Independent: 632 Aided: 342 Chair–bed bound: 7
Of the 1273 peritrochanteric fractures treated during the period of study, 63 did not come at the controls and 229 (18%) died during the first year postoperatively. This left 981 patients evaluated clinically and radiologically. Fractures were evaluated with the Kyle and Gustilo [15] classification based on four kind of decreasing-stability fractures. The preoperative data are summarised in Table 1. The operative technique followed the instructions of the manufactures. The IMHS is a 21 cm cannulated intramedullary nail with a reduced angle (4◦ ) of medio-lateral bending to allow the insertion into the great trochanter. The nail is used with a lag screw into the femoral head. A sleeve, which is held by a setscrew, passes through the intramedullary nail and over the lag screw. The sleeve prevents rotation and allows the lag screw to slide, so impaction of the fracture may occur under load. The IMHS nail is available in two angles (130 and 135◦ ) and in four
diameters (10, 12, 14 and 16 mm) to allow a proper fit within the femoral canal. Distal locking screws prevent rotation of the nail within the femur. It is available in an IMHS long stem (34, 38, 42 cm), with a proximal diameter of 10 mm and two angles of 130 and 135◦ , indicated in the subtrochanteric fractures extended to femoral shaft. Closed fracture reduction was performed under image intensifier control (Fig. 1a and b) and the IMHS-long stem version was used in 74 fractures (type III and IV). We performed an open reduction in 28 cases (Fig. 2a and b), owing to preoperative failure of reduction or intraoperative displacement of the fracture (Table 3). In these two groups there were no significant differences (duration of operation, blood loss, postoperative mobility, time to full weight bearing and mortality at one year) compared to the cases treated with standard IMHS and closed reduction. In the open reduction group we reported two superficial infection of the wound (Table 4). Antimicrobial and antithrombotic prophylaxis was given routinely. Partial weight bearing was allowed as soon as possible. Full weight bearing was begun after 1 month in the more comminuted fractures. Postoperative visits and radiographs were performed at 1, 3 and 6 months. The last group of patients was called for a review after a minimum of 1 year (mean 18 months, range 1–3 years). Intraoperative, postoperative complications and level of mobility were recorded.
3. Results We evaluated 981 fractures. Operative and postoperative data are summarised in Table 2. Full or partial weight bearing was allowed during the first week postoperatively in all
Fig. 1. Radiographs of a pertrochanteric fracture in a 75-year-old female: (a) preoperatively; (b) 8 months postinjury.
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
409
Fig. 2. Radiographs of a subtrochanteric fracture in a 72-year-old female treated with open reduction and a long IMHS: (a) preoperatively; (b) 3 months postinjury.
Table 2 Operative and postoperative data of the 981 patients with peritrochanteric femoral fractures
Table 4 Postoperative complications of the 981 patients with peritrochanteric femoral fractures
Mean Mean Mean Mean
Deep vein thrombosis: 23 Deep anaemia: 11 Embolia: 2 Sciatic paresis: 2 Emathoma: 23 Superficial wound infection: 2 Calcification: 2 Percentage: 6.6
duration of operation in minutes (range): 55 (45–135) blood loss in milliliter (range): 128 (85–400) duration of hospital stay in days (range): 14 (9–20) time to full weight bearing in weeks (range): 1 (0–4)
Postoperative mobility Independent: 388 Aided: 498 Chair–bed bound: 95
Table 3 Intraoperative complications of the 981 patients with peritrochanteric femoral fractures Failure of reduction: 10 Operative fracture displacement: 18 Failure of distal locking: 4 Femoral shaft fracture: 1 Fracture of lateral cortex: 4 Percentage: 3.7
the patients, but this was not possible in 9.7% of the patients, because of poor general conditions. Intraoperative complications are summarised in Table 3. The cases with failure of reduction and intraoperative displacement were treated with open reduction, wiring and a long IMHS. The intraoperative shaft fracture was immediately treated with a long IMHS. Table 4 summarises the postoperative complications and Table 5 those that needed a second operation.
The cut out complications, observed a few days to a month after weight bearing, were always related to a high-anterior position of the cephalic screw. All the cases of cut out and screws penetrated the acetabulum were treated with hip arthroplasty. Postoperative femoral shaft fractures occurred within the first three postoperative months after minimal trauma. Exchanging the nail for a long stem version treated postoperative femoral shaft fractures (Fig. 3a–h). Fracture healing was always observed in few months (average 2 months), less than in a case of non-union that was treated, after a year by hemiarthroplasty. By 12 months, 90.3% of Table 5 Postoperative complications of the 981 patients with peritrochanteric femoral fractures that needed a re-operation Postoperative femoral shaft fractures: 4 Head screw penetrated the acetabulum: 3 Cut out: 9 (in 21 risky cephalic screw position) Non-union: 1 Percentage: 1.7
410
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
Fig. 3. Radiographs of some complications: (a) 2 months postoperative femoral shaft fracture, (b) treated with a long IMHS; (c) screw cut out 3 months postoperatively; (d) treated with a total hip arthroplasty; (e) type III fracture and (f) intraoperative fracture of lateral cortex (arrow); (g) type I fracture and (h) head screw penetrated the acetabulum 4 months postoperatively.
the patients were able to walk with or without any aid, the others were unable to leave the bed or chair.
4. Discussion The use of intramedullary fixation methods has resulted in a high rate of union. However, intramedullary implants have been associated with new series of complications. Previous studies have reported the results of intertrochanteric fracture treated with sliding hip screw or Gamma nail (Howmedica) without finding substantial differences regarding operating time, duration of hospital stay, infection rate, wound complication, implant failure or screw cut out [1,3,5,19,20]. For many authors, the sliding hip screw still represents the standard implant in peritrochanteric stable fracture [1,3,12,25]. On the other hand, the use of the Gamma nail allowed full weight bearing and decreased the death rate from 17% (methods without full weight bearing) to 6% [6]. Taeger et al. [25] showed that complications, associated with dynamic screw osteosynthesis, appeared only in unstable fractures (7%). The advantages of treating unstable peritrochanteric fractures with Gamma nails include immediate full weight bearing without the risk of fracture dislocation or shortening of the limb [2,8,10,11].
However, Frohlich and Benko [9] observed more than 1 cm shortening in 47% of the cases treated with dynamic hip screw. Baumgaertner et al. [3] comparing intramedullary versus extramedullary fixation, have shown that the intramedullary devices are associated with 23% less surgical time and 44% less blood loss. However, the Gamma nail has been criticised for the increased risk of intra and postoperative femoral shaft fracture at the nail tip and at the insertion sites of the locking bolts (from 2.9 to 11%) [1,4,11,17,18,26]. In the Gamma nail, the compression loads are concentrated at the implant’s distal point of fixation [22,24]. This stress concentration is partially attributable to the interlocking screws and to the non-anatomic 10◦ valgus bend of the Gamma nails. Bridle et al. [5] reported postoperative femoral shaft fractures in 8% of cases in which the Gamma nail were not interlocked distally. The possible predisposing factors are the valgus angulation of the nail and overreaming [18]. The IMHS was mainly introduced to address this complication. The IMHS has a medio-lateral curve of 4◦ that does not cause three-point loading of the femur which is thought to increase the risk of fractures. In addition, the locking bolts require a smaller drill hole, which may reduce the incidence of fractures.
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
Nevertheless, Baumgartner et al. [3] reported three (4%) late femoral shaft fracture in 67 cases treated with IMHS. Two of these were associated with the use of a 16 mm diameter nail. Hardy et al. [12] reported only one intraoperative fracture of the femoral shaft in 50 fractures treated with IMHS (0.4%), due to insufficient reaming of the femoral canal and to hammering the nail. In our series, we reported only one intraoperative femoral shaft fracture (0.1%), due to an excessively lateral introduction of the nail, and four postoperative (0.4%), in all of which the femoral canal had been reamed or overreamed. In one case, the fracture was through a locking hole. These rates are lower than those reported with Gamma nail. In all the cases of screw cut out, the screw was inserted in to the upper half of the femoral head. We suggest, it is safe to use a thinner nail and only minimal force to introduce the nail. Since the distal part of the nail already produces a stress riser, distal locking screws should be used only when they are specifically indicated, for example in unstable fractures. The screw in the femoral head must always be long enough and inserted in to the central or lower portion of the femoral head in an antero-posterior plane and always in the central portion in the lateral plane. This can be obtained with a good preoperative reduction of the fracture, reducing the antiversion angle near to zero. Another advantage is the ability of the lag screw to slide, allowing impacting. Unfortunately the sliding cannot be stopped, so the assembly can never be really static. This is a disadvantage in type IV fractures. To limit cut out screw complications, we feel a nail with a 125◦ angle would be helpful.
5. Conclusion The IMHS nail allows an early recovery of the patients due to solid fixation. Our current treatment involves operative treatment with a standard IMHS with no distal locking for stable types I and II fracture patterns and IMHS with distal locking for unstable type III. For subtrochanteric fractures with intertrochanteric extension, we use the long IMHS. IMHS may be preferred to an open osteosynthesis in younger patients with multiple trauma, in patients with metastatic fractures and in non-union of trochanteric fractures initially treated with a plate. In our opinion, it is possible to reduce the main complications with correct preoperative planning, good preoperative reduction of the fracture and careful performance of the surgical technique. Poor positioning of the screw in the femoral head must be avoided.
Acknowledgements We thank Mrs. Laura Pastre from Department of Orthopaedics, Treviso, Italy for technical support.
411
References [1] Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma 2001;15(6):394–400. [2] Babst R, Martinet O, Renner N, Rosso R, Bodoky A, Heberer M, et al. The DHS (dynamic hip screw) buttress plate in the management of unstable proximal femoral fractures. Schweiz Med Wochenschr 1993;123(13):566–8. [3] Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop 1998;348:87–94. [4] Boriani S, De Iure F, Bettelli G, Specchia L, et al. The results of a multicenter Italian study on the use of the Gamma nail for treatment of pertrochanteric and subtrochanteric fractures: a review of 1181 cases. Chir Org Mov 1994;LXXIX:193–203. [5] Bridle SH, Patel AD, Bircher M, et al. Fixation of intertrochanteric fractures of the femur. A randomized prospective comparison of the Gamma nail and the dynamic hip screw. J Bone Joint Surg 1991;73B:330–4. [6] Buhl K, du Bois YD, Lamade W, Meeder PJ. The long Gamma nail—indications, technique and results. Chirurg 2000;71(9):1107– 14. [7] Dimon JH, Hughston JC. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg 1967;49-A(3):440–50. [8] Eberle C, Guyer P, Keller H, Metzger U. The Gamma nail—an ideal implant for treatment of unstable fractures in elderly patients. Helv Chir Acta 1993;59(4):527–31. [9] Frohlich P, Benko T. DHS (dynamic hip screw)-ostoesynthesis in the management of femoral fractures in the hip region and the place of this method in the treatment of such injuries. Magy Traumatol Ortop Kezseb Plasztikai Seb 1993;36(1):59–64. [10] Geissler N, Meffert O, Stapel A, Heymann H. Results of surgical management of unstable peritrochanteric femoral fractures with the dynamic hip screw and and T plate. Unfallchirurgie 1994;20(2):72–5 [Erratum in Unfallchirurgie 1994;20(3):184]. [11] Guyer P, Landolt M, Eberle C, Keller H. The Gamma nail as a resilient alternative to the dynamic hip screw in unstable proximal femoral fractures in the elderly. Helv Chir Acta 1992;58(5):697–703. [12] Hardy DCR, Descamps PY, Krallis P, Fabeck L, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. J Bone Joint Surg 1998;80-A(5):618–30. [13] Jensen JS, Sonne-Holm S. Critical analysis of Ender nailing in the treatment of trochanteric fractures. Acta Orthop Scand 1980;51(5):817–25. [14] Koval KJ, Falvo KA, Zuckerman JD. Intramedullary hip screw: indications and surgical technique. Oper Tech Orthop 1994;4(2):74– 82. [15] Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. A retrospective and prospective study. J Bone Joint Surg 1979;61-A:216–21. [16] Laros GS, Moore JF. Complications of fixation in intertrochanteric fractures. Clin Orthop 1974;101(1):110–9. [17] Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg 1992;74-B(3):345–51. [18] Mahaisavariya B, Laupattarakasem W. Craking of the femoral shaft by the Gamma nail. Injury 1992;23(7):493–500. [19] Parker MJ, Pryor GA. Gamma versus DHS nailing for extracapsular femoral fractures. Int Orthop 1996;20:163–8. [20] Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the dynamic hip screw and the Gamma locking nail. J Bone Joint Surg 1993;75-B(5):789–93. [21] Rantanen J, Aro TH. Intramedullary fixation of high subtrochanteric femoral fractures: a study comparing two implant designs, the
412
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
Gamma nail and the intramedullary hip screw. J Orthop Trauma 1998;12(4):249–52. [22] Rosenblum SF, Zuckerman JD, Kummer FJ, et al. A biomechanical evaluation of the Gamma nail. J Bone Joint Surg 1992;74B:352–7. [23] Sarmiento A, Williams EM. The unstable intertrochanteric fracture: treatment with a valgus osteotomy and I-beam nail-plate. A preliminary report of 100 cases. J Bone Joint Surg 1970;52A(7):1309–18.
[24] Shaw JA, Wilson S. Internal fixation of proximal femur fractures: a biomechanical comparison of the Gamma locking nail and the omega compression hip screw. Orthop Rev 1993;22:61–8. [25] Taeger G, Schmid C, Zettl R, Schweiberer L, Nast-Kolb D. Stable and unstable pertrochanteric femoral fractures. Differentiated indications for the dynamic hip screw. Unfallchirurg 2000;103(9):741–8. [26] Williams WW, Parker BC. Complications associated with the use of the Gamma nail. Injury 1992;23(5):291–2.
IMHS clinical experience in the treatment of peritrochanteric fractures The results of a multicentric Italian study of 981 cases E. Rebuzzi a,∗ , A. Pannone a , S. Schiavetti a , P. Santoriello a , U. de Nicola a , G. Fancellu b , P. Cau b , S. Gulli b , P. Dordolin b , P. Maniscalco c , F. Morici d , M. Commessatti d , M. Pozzi-Mucelli e , C.S. Maiorana e , F. Bassini e a
e
Department of Orthopaedics, Treviso, Italy b University of Trieste, Trieste, Italy c University of Siena, Siena, Italy d VI Division Orthopaedic Institute Rizzoli, Bologna, Italy Operative Unity of Orthopaedics, A.S.S.N. 3, Alto Friuli, Italy Accepted 27 March 2002
Abstract This retrospective study evaluates the results obtained in five Italian departments of traumatology in the treatment of peritrochanteric (pertrochanteric and subtrochanteric) fractures by the intramedullary hip screw (IMHS; Smith & Nephew Richards, Memphis, TN, USA) nail. One thousand two hundred and seventy-three patients were treated with the IMHS nail between March 1992 and February 2000. The results of these operations were evaluated clinically and radiological in 981 patients. The 90.3% of patients could walk unaided or with simple support. Because of the low complication rate requiring re-operation (postoperative shaft fractures, screw penetrated the acetabulum, cut out and non-union) (1.7%), we think that this device is an advance in the treatment of peritrochanteric fractures. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction Surgical treatment of peritrochanteric fractures has evolved during the last 40 years. The early rigid nail-plate devices did not allow fracture impaction. This caused mechanical complications when an unstable fracture collapsed into a more stable position. Later in the 1960s, displacement osteotomies were developed to convert unstable to stable fractures [7,23]. Unfortunately, mechanical problems of additional impaction persisted [16]. In the 1970s, sliding nail and screw devices became popular. These devices are load sharing and allow early mobilisation and weight bearing without the risk of fixation failure, typical of the load bearing rigid nail-plate devices [14]. Intramedullary fixation with the Ender nail was also used. The advantage of this technique was a minimal surgical approach with low blood loss, but several complications were reported. Jensen and Sonne-Holm [13] reported a 46% re-operations rate in unsta∗
Corresponding author. Present address: Via Garibaldi 73, 33080 Cecchini di Pasiano, Pordenone, Italy. Tel.: +43-0422-715329; fax: +43-0422-715401. E-mail address: [email protected] (E. Rebuzzi).
ble fractures treated by Ender nailing. Nowadays, the most commonly used methods are various types of screw-plates or interlocking nails. The interlocking nails are designed to apply the principles of locked intramedullary nailing and lag screw fixation in the treatment of peritrochanteric and high subtrochanteric fractures. Theoretically, the use of an intramedullary device should decrease the bending lever arm and torsion force, resulting in less implant stress [14,20]. Reported complications of interlocking nailing include poor positioning of the screw in the head, secondary dislocation of the fracture during the insertion of the nail, cut out, thigh discomfort, tip impingement and fractures of the femoral shaft. These may be caused by errors of indication, implant design, iatrogenic or induced errors of technique during the learning curve [4,17,20,26]. The IMHS was developed to overcome these problems [3,12,21]. 2. Materials and methods The five centres were given a form for clinical and radiographic evaluation (type of fracture, sex and age, preoperative and final ability to walk, surgical technique, time of consolidation, intra- and postoperative complications).
0020-1383/02/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 2 ) 0 0 0 7 0 - 0
408
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
Table 1 Preoperative data of the 981 patients with peritrochanteric femoral fractures Mean age in years (range): 80.77 (36–104) Male/females: 1:4 Side of fracture (l:r): l = r Fracture pattern (Kyle–Gustilo) type: I (451), II (250), III (179), IV (101) Pathological fractures: 10 Non-union: 1 Bifocal: 1 Preoperative mobility Independent: 632 Aided: 342 Chair–bed bound: 7
Of the 1273 peritrochanteric fractures treated during the period of study, 63 did not come at the controls and 229 (18%) died during the first year postoperatively. This left 981 patients evaluated clinically and radiologically. Fractures were evaluated with the Kyle and Gustilo [15] classification based on four kind of decreasing-stability fractures. The preoperative data are summarised in Table 1. The operative technique followed the instructions of the manufactures. The IMHS is a 21 cm cannulated intramedullary nail with a reduced angle (4◦ ) of medio-lateral bending to allow the insertion into the great trochanter. The nail is used with a lag screw into the femoral head. A sleeve, which is held by a setscrew, passes through the intramedullary nail and over the lag screw. The sleeve prevents rotation and allows the lag screw to slide, so impaction of the fracture may occur under load. The IMHS nail is available in two angles (130 and 135◦ ) and in four
diameters (10, 12, 14 and 16 mm) to allow a proper fit within the femoral canal. Distal locking screws prevent rotation of the nail within the femur. It is available in an IMHS long stem (34, 38, 42 cm), with a proximal diameter of 10 mm and two angles of 130 and 135◦ , indicated in the subtrochanteric fractures extended to femoral shaft. Closed fracture reduction was performed under image intensifier control (Fig. 1a and b) and the IMHS-long stem version was used in 74 fractures (type III and IV). We performed an open reduction in 28 cases (Fig. 2a and b), owing to preoperative failure of reduction or intraoperative displacement of the fracture (Table 3). In these two groups there were no significant differences (duration of operation, blood loss, postoperative mobility, time to full weight bearing and mortality at one year) compared to the cases treated with standard IMHS and closed reduction. In the open reduction group we reported two superficial infection of the wound (Table 4). Antimicrobial and antithrombotic prophylaxis was given routinely. Partial weight bearing was allowed as soon as possible. Full weight bearing was begun after 1 month in the more comminuted fractures. Postoperative visits and radiographs were performed at 1, 3 and 6 months. The last group of patients was called for a review after a minimum of 1 year (mean 18 months, range 1–3 years). Intraoperative, postoperative complications and level of mobility were recorded.
3. Results We evaluated 981 fractures. Operative and postoperative data are summarised in Table 2. Full or partial weight bearing was allowed during the first week postoperatively in all
Fig. 1. Radiographs of a pertrochanteric fracture in a 75-year-old female: (a) preoperatively; (b) 8 months postinjury.
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
409
Fig. 2. Radiographs of a subtrochanteric fracture in a 72-year-old female treated with open reduction and a long IMHS: (a) preoperatively; (b) 3 months postinjury.
Table 2 Operative and postoperative data of the 981 patients with peritrochanteric femoral fractures
Table 4 Postoperative complications of the 981 patients with peritrochanteric femoral fractures
Mean Mean Mean Mean
Deep vein thrombosis: 23 Deep anaemia: 11 Embolia: 2 Sciatic paresis: 2 Emathoma: 23 Superficial wound infection: 2 Calcification: 2 Percentage: 6.6
duration of operation in minutes (range): 55 (45–135) blood loss in milliliter (range): 128 (85–400) duration of hospital stay in days (range): 14 (9–20) time to full weight bearing in weeks (range): 1 (0–4)
Postoperative mobility Independent: 388 Aided: 498 Chair–bed bound: 95
Table 3 Intraoperative complications of the 981 patients with peritrochanteric femoral fractures Failure of reduction: 10 Operative fracture displacement: 18 Failure of distal locking: 4 Femoral shaft fracture: 1 Fracture of lateral cortex: 4 Percentage: 3.7
the patients, but this was not possible in 9.7% of the patients, because of poor general conditions. Intraoperative complications are summarised in Table 3. The cases with failure of reduction and intraoperative displacement were treated with open reduction, wiring and a long IMHS. The intraoperative shaft fracture was immediately treated with a long IMHS. Table 4 summarises the postoperative complications and Table 5 those that needed a second operation.
The cut out complications, observed a few days to a month after weight bearing, were always related to a high-anterior position of the cephalic screw. All the cases of cut out and screws penetrated the acetabulum were treated with hip arthroplasty. Postoperative femoral shaft fractures occurred within the first three postoperative months after minimal trauma. Exchanging the nail for a long stem version treated postoperative femoral shaft fractures (Fig. 3a–h). Fracture healing was always observed in few months (average 2 months), less than in a case of non-union that was treated, after a year by hemiarthroplasty. By 12 months, 90.3% of Table 5 Postoperative complications of the 981 patients with peritrochanteric femoral fractures that needed a re-operation Postoperative femoral shaft fractures: 4 Head screw penetrated the acetabulum: 3 Cut out: 9 (in 21 risky cephalic screw position) Non-union: 1 Percentage: 1.7
410
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
Fig. 3. Radiographs of some complications: (a) 2 months postoperative femoral shaft fracture, (b) treated with a long IMHS; (c) screw cut out 3 months postoperatively; (d) treated with a total hip arthroplasty; (e) type III fracture and (f) intraoperative fracture of lateral cortex (arrow); (g) type I fracture and (h) head screw penetrated the acetabulum 4 months postoperatively.
the patients were able to walk with or without any aid, the others were unable to leave the bed or chair.
4. Discussion The use of intramedullary fixation methods has resulted in a high rate of union. However, intramedullary implants have been associated with new series of complications. Previous studies have reported the results of intertrochanteric fracture treated with sliding hip screw or Gamma nail (Howmedica) without finding substantial differences regarding operating time, duration of hospital stay, infection rate, wound complication, implant failure or screw cut out [1,3,5,19,20]. For many authors, the sliding hip screw still represents the standard implant in peritrochanteric stable fracture [1,3,12,25]. On the other hand, the use of the Gamma nail allowed full weight bearing and decreased the death rate from 17% (methods without full weight bearing) to 6% [6]. Taeger et al. [25] showed that complications, associated with dynamic screw osteosynthesis, appeared only in unstable fractures (7%). The advantages of treating unstable peritrochanteric fractures with Gamma nails include immediate full weight bearing without the risk of fracture dislocation or shortening of the limb [2,8,10,11].
However, Frohlich and Benko [9] observed more than 1 cm shortening in 47% of the cases treated with dynamic hip screw. Baumgaertner et al. [3] comparing intramedullary versus extramedullary fixation, have shown that the intramedullary devices are associated with 23% less surgical time and 44% less blood loss. However, the Gamma nail has been criticised for the increased risk of intra and postoperative femoral shaft fracture at the nail tip and at the insertion sites of the locking bolts (from 2.9 to 11%) [1,4,11,17,18,26]. In the Gamma nail, the compression loads are concentrated at the implant’s distal point of fixation [22,24]. This stress concentration is partially attributable to the interlocking screws and to the non-anatomic 10◦ valgus bend of the Gamma nails. Bridle et al. [5] reported postoperative femoral shaft fractures in 8% of cases in which the Gamma nail were not interlocked distally. The possible predisposing factors are the valgus angulation of the nail and overreaming [18]. The IMHS was mainly introduced to address this complication. The IMHS has a medio-lateral curve of 4◦ that does not cause three-point loading of the femur which is thought to increase the risk of fractures. In addition, the locking bolts require a smaller drill hole, which may reduce the incidence of fractures.
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
Nevertheless, Baumgartner et al. [3] reported three (4%) late femoral shaft fracture in 67 cases treated with IMHS. Two of these were associated with the use of a 16 mm diameter nail. Hardy et al. [12] reported only one intraoperative fracture of the femoral shaft in 50 fractures treated with IMHS (0.4%), due to insufficient reaming of the femoral canal and to hammering the nail. In our series, we reported only one intraoperative femoral shaft fracture (0.1%), due to an excessively lateral introduction of the nail, and four postoperative (0.4%), in all of which the femoral canal had been reamed or overreamed. In one case, the fracture was through a locking hole. These rates are lower than those reported with Gamma nail. In all the cases of screw cut out, the screw was inserted in to the upper half of the femoral head. We suggest, it is safe to use a thinner nail and only minimal force to introduce the nail. Since the distal part of the nail already produces a stress riser, distal locking screws should be used only when they are specifically indicated, for example in unstable fractures. The screw in the femoral head must always be long enough and inserted in to the central or lower portion of the femoral head in an antero-posterior plane and always in the central portion in the lateral plane. This can be obtained with a good preoperative reduction of the fracture, reducing the antiversion angle near to zero. Another advantage is the ability of the lag screw to slide, allowing impacting. Unfortunately the sliding cannot be stopped, so the assembly can never be really static. This is a disadvantage in type IV fractures. To limit cut out screw complications, we feel a nail with a 125◦ angle would be helpful.
5. Conclusion The IMHS nail allows an early recovery of the patients due to solid fixation. Our current treatment involves operative treatment with a standard IMHS with no distal locking for stable types I and II fracture patterns and IMHS with distal locking for unstable type III. For subtrochanteric fractures with intertrochanteric extension, we use the long IMHS. IMHS may be preferred to an open osteosynthesis in younger patients with multiple trauma, in patients with metastatic fractures and in non-union of trochanteric fractures initially treated with a plate. In our opinion, it is possible to reduce the main complications with correct preoperative planning, good preoperative reduction of the fracture and careful performance of the surgical technique. Poor positioning of the screw in the femoral head must be avoided.
Acknowledgements We thank Mrs. Laura Pastre from Department of Orthopaedics, Treviso, Italy for technical support.
411
References [1] Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma 2001;15(6):394–400. [2] Babst R, Martinet O, Renner N, Rosso R, Bodoky A, Heberer M, et al. The DHS (dynamic hip screw) buttress plate in the management of unstable proximal femoral fractures. Schweiz Med Wochenschr 1993;123(13):566–8. [3] Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop 1998;348:87–94. [4] Boriani S, De Iure F, Bettelli G, Specchia L, et al. The results of a multicenter Italian study on the use of the Gamma nail for treatment of pertrochanteric and subtrochanteric fractures: a review of 1181 cases. Chir Org Mov 1994;LXXIX:193–203. [5] Bridle SH, Patel AD, Bircher M, et al. Fixation of intertrochanteric fractures of the femur. A randomized prospective comparison of the Gamma nail and the dynamic hip screw. J Bone Joint Surg 1991;73B:330–4. [6] Buhl K, du Bois YD, Lamade W, Meeder PJ. The long Gamma nail—indications, technique and results. Chirurg 2000;71(9):1107– 14. [7] Dimon JH, Hughston JC. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg 1967;49-A(3):440–50. [8] Eberle C, Guyer P, Keller H, Metzger U. The Gamma nail—an ideal implant for treatment of unstable fractures in elderly patients. Helv Chir Acta 1993;59(4):527–31. [9] Frohlich P, Benko T. DHS (dynamic hip screw)-ostoesynthesis in the management of femoral fractures in the hip region and the place of this method in the treatment of such injuries. Magy Traumatol Ortop Kezseb Plasztikai Seb 1993;36(1):59–64. [10] Geissler N, Meffert O, Stapel A, Heymann H. Results of surgical management of unstable peritrochanteric femoral fractures with the dynamic hip screw and and T plate. Unfallchirurgie 1994;20(2):72–5 [Erratum in Unfallchirurgie 1994;20(3):184]. [11] Guyer P, Landolt M, Eberle C, Keller H. The Gamma nail as a resilient alternative to the dynamic hip screw in unstable proximal femoral fractures in the elderly. Helv Chir Acta 1992;58(5):697–703. [12] Hardy DCR, Descamps PY, Krallis P, Fabeck L, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. J Bone Joint Surg 1998;80-A(5):618–30. [13] Jensen JS, Sonne-Holm S. Critical analysis of Ender nailing in the treatment of trochanteric fractures. Acta Orthop Scand 1980;51(5):817–25. [14] Koval KJ, Falvo KA, Zuckerman JD. Intramedullary hip screw: indications and surgical technique. Oper Tech Orthop 1994;4(2):74– 82. [15] Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. A retrospective and prospective study. J Bone Joint Surg 1979;61-A:216–21. [16] Laros GS, Moore JF. Complications of fixation in intertrochanteric fractures. Clin Orthop 1974;101(1):110–9. [17] Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg 1992;74-B(3):345–51. [18] Mahaisavariya B, Laupattarakasem W. Craking of the femoral shaft by the Gamma nail. Injury 1992;23(7):493–500. [19] Parker MJ, Pryor GA. Gamma versus DHS nailing for extracapsular femoral fractures. Int Orthop 1996;20:163–8. [20] Radford PJ, Needoff M, Webb JK. A prospective randomised comparison of the dynamic hip screw and the Gamma locking nail. J Bone Joint Surg 1993;75-B(5):789–93. [21] Rantanen J, Aro TH. Intramedullary fixation of high subtrochanteric femoral fractures: a study comparing two implant designs, the
412
E. Rebuzzi et al. / Injury, Int. J. Care Injured 33 (2002) 407–412
Gamma nail and the intramedullary hip screw. J Orthop Trauma 1998;12(4):249–52. [22] Rosenblum SF, Zuckerman JD, Kummer FJ, et al. A biomechanical evaluation of the Gamma nail. J Bone Joint Surg 1992;74B:352–7. [23] Sarmiento A, Williams EM. The unstable intertrochanteric fracture: treatment with a valgus osteotomy and I-beam nail-plate. A preliminary report of 100 cases. J Bone Joint Surg 1970;52A(7):1309–18.
[24] Shaw JA, Wilson S. Internal fixation of proximal femur fractures: a biomechanical comparison of the Gamma locking nail and the omega compression hip screw. Orthop Rev 1993;22:61–8. [25] Taeger G, Schmid C, Zettl R, Schweiberer L, Nast-Kolb D. Stable and unstable pertrochanteric femoral fractures. Differentiated indications for the dynamic hip screw. Unfallchirurg 2000;103(9):741–8. [26] Williams WW, Parker BC. Complications associated with the use of the Gamma nail. Injury 1992;23(5):291–2.