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Interlocking nails for femoral fractures: an initial experience
Injury (1991) 22, (2)‘ 93-96
93
Printed in Great Britain
Interlocking experience
nails for femoral fractures: an initial
R. S. Majkowski and A. S. Baker Bristol Royal Infirmary, Bristol, UK
We report the restclts of the first 50 femoral interlocking nails used in our city. The operations were performed by 20 different surgeons. The follow-up interval averaged 19 months.Five patients with pathological fractures died during this period and two could not be traced. Forty-three fractures were as935ed cliniudly and radiologimlly by one of the authors. h4&4nion and/or shortening occmed in 22 patients. Six patie& had varu5 (> 5’), tenpatients valp (> 5”) and tenpatients had malrotation I> I$). Six patients were stiened (> 2 cm). Two cases progresseh to non-union (> 26 weeks), and one ha~Ideep sepsis. We discuss the effect of insertion point
distal. The comminution was graded according to the criteria of Winquist et al. (1984). Type 1 included fractures without comminution. Type 2 had a butterfly fragment, but at least SO per cent of the opposing cortices were intact. Type 3 had a larger butterfly fragment and less than SO per cent of the opposing cortices were intact. Type 4 comminution had no abutment of the cortices. For assessment, the patients were divided into three groups according to the level of the fracture. The particular points that were sought in our analysis of the results are listed in Table 1. Delayed union was defined as the lack of progressive fracture consolidation between 16 and 24 weeks. Non-union was defined as pain on motion of the fracture site with no radiographic evidence of healing at 26 weeks (Christie et al., 1988).
malulignment.
Results Introduction The introduction of interlocking nails has created new standards of care for fractures of the femoral shaft. As a procedure it is technically demanding. This study was undertaken to identify difficulties that were encountered following its introduction to a general trauma unit. The findings therefore have direct relevance to any group of surgeons wishing to use interlocking nails.
Materials and methods Between August 1985 and January 1989, 50 patients had femoral fractures treated with interlocking nails. There were 35 male and 15 female patients, with an average age of 40 years (range 15-83 years). Seven of the fractures were pathological. Six fractures were open; five were grade 1, and one was grade 2 (Gustilo and Anderson, 1976). Surgery was performed from 0-20 days after admission (mean 4.94 days) using the GrosseKempf (31) or the A0 (19) universal nails. A total of 27 fractures were fixed in the static mode with cross screws above and below the fracture and 23 in the dynamic mode with cross screws at one end. The fractures were classified radiologically into proximal, mid-shaft, or 0020-1383/91/020093-04 0 1991 Butterworth-Heinemann
Ltd
Of the seven patients with pathological fractures, five died during the follow-up period. Two patients were lost to follow-up. The remaining 43 patients were reviewed clinically and radiologically by one of the authors between 6 and 39 months after operation (mean 19 months). Varus malunion [ > S”] This occurred in six patients with a mean of 6.3” (maximum IO”). Four of these cases occurred in proximal third fractures.
Valgus malalignment [ > 57 This occurred in ten patients with a mean of 8.1” (maximum 12”). Seven of these cases occurred in fractures of the distal third of the femur. Table I. Parameters used to assess results 1. 2. 3. 4. 5. 6.
Varus/valgus malalignment greater than 5 lntraoperative fracture comminution. Rotational deformity greater than lo’. Shortening greater than 2 cm. Non-union. Sepsis.
Injury: the BritishJournalof Accident Surgery (1991) Vol.
94
22/No.
2
Intraoperative fracture comminution
Four cases had further comminution time of surgery.
of their fracture at the
Rotational malalignment [ > lo”] This occurred in ten patients (maximum 30”). Two of these were internal rotation deformities. Shortening [ > 2 cm]
This occurred in six patients (maximum 3.5 cm). Delayed and non-union
Delayed union occurred in three cases. There were two cases of non-union, one in a boy aged 16 years and the other in a man aged 35 years. Both cases were closed proximal third fractures treated by intramedullary nails locked at the proximal end only. The first case developed a hypertrophic non-union and the nail fractured 9 months after injury. In the second case the proximal screw broke at I year. Radiographs showed an atrophic non-union. Both cases went on to union after revision of the nail and bone grafting. Sepsis
Two patients suffered wound infections. The first case had a superficial wound infection which responded to antibiotic treatment. The second case was a patient with multiple sclerosis who developed decubitus ulcers around her buttock area. The initial fixation of the fracture had been inadequate and a further open reduction was performed with supplementary fixation. The wound became infected with the formation of a sinus. Further surgical intervention was not considered because of the patient’s poor health. The fracture has united but the wound continues to discharge 36 months later.
Figure 1. Varus malalignment point.
and the trochanteric
insertion
Discussion In ten of the 34 patients with proximal and mid-shaft fractures, the trochanteric insertion point was used. Five of the six patients with varus malalignment and three of the four patients with intraoperative fracture comminution were in this group (Table 11). Figwe f illustrates unstable varus malalignment following a proximal third fracture where the trochanteric insertion point was used. This patient developed a hypertrophic non-union and subsequently required renailing when the initial nail fractured. Figttres 2 and 3 illustrate a case where use of the trochanteric insertion point caused further comminution of the medial aspect of the proximal fragment. We therefore recommend in agreement with Winquist et al. (1984), Wiss et al. (1986) and Browner (1986), that the piriform fossa insertion point should be used at all times, particularly for proximal and mid-shaft fractures. Particular difficulty was encountered in patients with
Table II. The incidence of varus/valgus malalignment fracture comminution in proximal and middle third fractures
lntraoperative fracture comminution
point
Varus
Valgus
Greater trochanter (10) Piriform fossa (24)
4
0
3
0
3
1
Insertion
and
distal third fractures who had poor bone stock. Of the six patients in this group, five developed important valgus malaiignment and two required supplementary internal fixation at a subsequent operation. We do not consider these fractures suitable for internal fixation by standard interlocking nail techniques. The patients were operated on in the lateral position. Correct rotational alignment may be difficult to assess in this position. In addition there is a tendency for the leg to sag into valgus. It has been suggested that this tendency may be counteracted by oblique insertion of the femoral traction pin from proximal lateral to distal medial (Winquist,l984; Browner, 1986). For these two reasons of rotational and valgus malalignment, it is recommended that the supine table position is used as suggested by Kempf et al. (1985), Browner (1986) and Klemm and Bomer (1986). Of the six fractures with shortening, four were fixed in the dynamic mode. There was no evidence that use of the static mode affected the rate of fracture union. Indeed, the two cases that progressed to non-union, had had their fractures fixed in the dynamic mode. It is recommended that the static mode should be used wherever possible for the majority of fractures. Overall there were 16 patients with either malunion or shortening and six patients with both. Results using other methods of treatment are shown in
Majkowski and Baker: Interlocking nails for femoral fractures
95
Figure 2. a, Intraoperative fracture comminution and b, the trochanteric
Table III. Direct comparison is invidious because of the diverse composition of fractures in different series in terms of age of patients, fracture site and fracture comminution. Each treatment has specific drawbacks. Traction requires a period of hospital admission often exceeding 12 weeks and may result in a high incidence of reduced knee flexion unless knee movement is started early on a split bed (Buxton, 1981). Cast bracing is unsuitable for proximal third fractures and requires an initial period of traction of up to 5 weeks (Hardy, 1983). All methods of conservative treatment are unsuitable for patients with multiple long bone fractures. Internal fixation with DC plates has fallen into disfavour
Table III. Comparative
insertion point.
because of the high incidence of infection and implant failure (Margerl et al., 1979). Although the incidence of shortening and malunion may appear to be quite high, this series comprised a preselected group with the most complicated fracture patterns. There was only one angulatory deformity greater than IO” and shortening did not exceed 3.5 cm. The incidence of malrotation after surgery may be lower than the figure given, as 10 per cent of normal adults show a discrepancy of 10” or greater in anteversion of the femoral neck (Brouwer, 1981). Inpatient stay was less than 30 days in 74 per cent of patients.
reds
Treatment
Author
Perkins traction Russell traction Cast bracing Cast bracing DC plate Interlocking nail
Buxton (1981) Anderson (1967) Sarmiento and Latta (1981) Hardy (1983) Magerl et al. (1979) Majkowski and Baker
Number
Shortening >2cm
Varus/valgus angulation > 5’
50 59 245 108 86 43
6% 6.7% Not given 12% 0% 13%
Not given 40% 59% 30% 9% 32%
Lnjury: the British Journal of Accident Surgery (1991) Vol. 22/No.
96
Conclusion Closed locked intramedullary nailing of femoral shaft fractures is undoubtedly a challenging technique with a learning curve. However, with the alterations in technique described, we feel that satisfactory results can be achieved even in relatively
inexperienced
hands.
References Anderson R. L. (1967) Conservative treatment of fractures of the femur. 1. Bone joint Surg. @A, 1371. Brouwer K. J. (1981) Torsional deformities after fractures of the femoral shaft in childhood. A retrospective study, 27-32 years after trauma. Acfu Orfhop. Stand. Suppl. 195. Browner B. D. (1986) Pitfalls, errors and complications in the use of locking Kiintscher nails. Qin. Orthop. 212.192. Buxton R. A. (2981) The use of Perkins’ traction in the treatment ot femoral shaft fractures. 1. &me Joint Surg. 63B, 362. Christie J., Court-Brown C., Kinninmonth A. W. G. et al. (19881 Intramedullary locking nails in the management of femoral shaft fractures. 1. Bone joint Surg. 7OB, 206. Gustilo R. B. and Anderson J. (1976) Prevention of infection in the treatment of one thousand and twenty-five fractures of long bones. 1. Bone Joint Surg. .58A, 453.
2
Hardy A. E. (1983) The treatment of femoral fractures by cast-brace application and early ambulation. J. Bone Joint Surg. 65A, 56. Kempf I., Grosse A. and Beck G. (1985) Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J. Bone ]oinf Surg. 6 7A, 709. Klemm K. W. and Bomer M. (1986) Interlocking nailing of complex fractures of the femur and tibia. Clin. Or&p. 212,89. Magerl F., Wyss A., Brunner C. et al. (1979) Plate osteosynthesis of femoral shaft fractures in adults. Clin. Orfhop. 138,62. Sarmiento A. and Latta L. L. (1981). Closed Fttncfional Treattnent of Fracfures. Berlin Heidelberg New York: Springer-Verlag, 336. Winquist R. A., Hansen S. T. Jr and Clawson D. K. (1984) Closed intramedullary nailing of femoral fractures. J, Bone Joint Surg. 66A, 529. Wiss D. A., Fleming C. H., Matta J. M. et al (1986) Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. Clin. Orthop. 212,35.
Paper accepted
10 August
1990.
Requesfs for reprints should be addressed to: R. S. Majkowski FRCS, 50 King George Close, Charlton Park, Cheltenham, Gloucestershire GL53 7RW, UK.
93
Printed in Great Britain
Interlocking experience
nails for femoral fractures: an initial
R. S. Majkowski and A. S. Baker Bristol Royal Infirmary, Bristol, UK
We report the restclts of the first 50 femoral interlocking nails used in our city. The operations were performed by 20 different surgeons. The follow-up interval averaged 19 months.Five patients with pathological fractures died during this period and two could not be traced. Forty-three fractures were as935ed cliniudly and radiologimlly by one of the authors. h4&4nion and/or shortening occmed in 22 patients. Six patie& had varu5 (> 5’), tenpatients valp (> 5”) and tenpatients had malrotation I> I$). Six patients were stiened (> 2 cm). Two cases progresseh to non-union (> 26 weeks), and one ha~Ideep sepsis. We discuss the effect of insertion point
distal. The comminution was graded according to the criteria of Winquist et al. (1984). Type 1 included fractures without comminution. Type 2 had a butterfly fragment, but at least SO per cent of the opposing cortices were intact. Type 3 had a larger butterfly fragment and less than SO per cent of the opposing cortices were intact. Type 4 comminution had no abutment of the cortices. For assessment, the patients were divided into three groups according to the level of the fracture. The particular points that were sought in our analysis of the results are listed in Table 1. Delayed union was defined as the lack of progressive fracture consolidation between 16 and 24 weeks. Non-union was defined as pain on motion of the fracture site with no radiographic evidence of healing at 26 weeks (Christie et al., 1988).
malulignment.
Results Introduction The introduction of interlocking nails has created new standards of care for fractures of the femoral shaft. As a procedure it is technically demanding. This study was undertaken to identify difficulties that were encountered following its introduction to a general trauma unit. The findings therefore have direct relevance to any group of surgeons wishing to use interlocking nails.
Materials and methods Between August 1985 and January 1989, 50 patients had femoral fractures treated with interlocking nails. There were 35 male and 15 female patients, with an average age of 40 years (range 15-83 years). Seven of the fractures were pathological. Six fractures were open; five were grade 1, and one was grade 2 (Gustilo and Anderson, 1976). Surgery was performed from 0-20 days after admission (mean 4.94 days) using the GrosseKempf (31) or the A0 (19) universal nails. A total of 27 fractures were fixed in the static mode with cross screws above and below the fracture and 23 in the dynamic mode with cross screws at one end. The fractures were classified radiologically into proximal, mid-shaft, or 0020-1383/91/020093-04 0 1991 Butterworth-Heinemann
Ltd
Of the seven patients with pathological fractures, five died during the follow-up period. Two patients were lost to follow-up. The remaining 43 patients were reviewed clinically and radiologically by one of the authors between 6 and 39 months after operation (mean 19 months). Varus malunion [ > S”] This occurred in six patients with a mean of 6.3” (maximum IO”). Four of these cases occurred in proximal third fractures.
Valgus malalignment [ > 57 This occurred in ten patients with a mean of 8.1” (maximum 12”). Seven of these cases occurred in fractures of the distal third of the femur. Table I. Parameters used to assess results 1. 2. 3. 4. 5. 6.
Varus/valgus malalignment greater than 5 lntraoperative fracture comminution. Rotational deformity greater than lo’. Shortening greater than 2 cm. Non-union. Sepsis.
Injury: the BritishJournalof Accident Surgery (1991) Vol.
94
22/No.
2
Intraoperative fracture comminution
Four cases had further comminution time of surgery.
of their fracture at the
Rotational malalignment [ > lo”] This occurred in ten patients (maximum 30”). Two of these were internal rotation deformities. Shortening [ > 2 cm]
This occurred in six patients (maximum 3.5 cm). Delayed and non-union
Delayed union occurred in three cases. There were two cases of non-union, one in a boy aged 16 years and the other in a man aged 35 years. Both cases were closed proximal third fractures treated by intramedullary nails locked at the proximal end only. The first case developed a hypertrophic non-union and the nail fractured 9 months after injury. In the second case the proximal screw broke at I year. Radiographs showed an atrophic non-union. Both cases went on to union after revision of the nail and bone grafting. Sepsis
Two patients suffered wound infections. The first case had a superficial wound infection which responded to antibiotic treatment. The second case was a patient with multiple sclerosis who developed decubitus ulcers around her buttock area. The initial fixation of the fracture had been inadequate and a further open reduction was performed with supplementary fixation. The wound became infected with the formation of a sinus. Further surgical intervention was not considered because of the patient’s poor health. The fracture has united but the wound continues to discharge 36 months later.
Figure 1. Varus malalignment point.
and the trochanteric
insertion
Discussion In ten of the 34 patients with proximal and mid-shaft fractures, the trochanteric insertion point was used. Five of the six patients with varus malalignment and three of the four patients with intraoperative fracture comminution were in this group (Table 11). Figwe f illustrates unstable varus malalignment following a proximal third fracture where the trochanteric insertion point was used. This patient developed a hypertrophic non-union and subsequently required renailing when the initial nail fractured. Figttres 2 and 3 illustrate a case where use of the trochanteric insertion point caused further comminution of the medial aspect of the proximal fragment. We therefore recommend in agreement with Winquist et al. (1984), Wiss et al. (1986) and Browner (1986), that the piriform fossa insertion point should be used at all times, particularly for proximal and mid-shaft fractures. Particular difficulty was encountered in patients with
Table II. The incidence of varus/valgus malalignment fracture comminution in proximal and middle third fractures
lntraoperative fracture comminution
point
Varus
Valgus
Greater trochanter (10) Piriform fossa (24)
4
0
3
0
3
1
Insertion
and
distal third fractures who had poor bone stock. Of the six patients in this group, five developed important valgus malaiignment and two required supplementary internal fixation at a subsequent operation. We do not consider these fractures suitable for internal fixation by standard interlocking nail techniques. The patients were operated on in the lateral position. Correct rotational alignment may be difficult to assess in this position. In addition there is a tendency for the leg to sag into valgus. It has been suggested that this tendency may be counteracted by oblique insertion of the femoral traction pin from proximal lateral to distal medial (Winquist,l984; Browner, 1986). For these two reasons of rotational and valgus malalignment, it is recommended that the supine table position is used as suggested by Kempf et al. (1985), Browner (1986) and Klemm and Bomer (1986). Of the six fractures with shortening, four were fixed in the dynamic mode. There was no evidence that use of the static mode affected the rate of fracture union. Indeed, the two cases that progressed to non-union, had had their fractures fixed in the dynamic mode. It is recommended that the static mode should be used wherever possible for the majority of fractures. Overall there were 16 patients with either malunion or shortening and six patients with both. Results using other methods of treatment are shown in
Majkowski and Baker: Interlocking nails for femoral fractures
95
Figure 2. a, Intraoperative fracture comminution and b, the trochanteric
Table III. Direct comparison is invidious because of the diverse composition of fractures in different series in terms of age of patients, fracture site and fracture comminution. Each treatment has specific drawbacks. Traction requires a period of hospital admission often exceeding 12 weeks and may result in a high incidence of reduced knee flexion unless knee movement is started early on a split bed (Buxton, 1981). Cast bracing is unsuitable for proximal third fractures and requires an initial period of traction of up to 5 weeks (Hardy, 1983). All methods of conservative treatment are unsuitable for patients with multiple long bone fractures. Internal fixation with DC plates has fallen into disfavour
Table III. Comparative
insertion point.
because of the high incidence of infection and implant failure (Margerl et al., 1979). Although the incidence of shortening and malunion may appear to be quite high, this series comprised a preselected group with the most complicated fracture patterns. There was only one angulatory deformity greater than IO” and shortening did not exceed 3.5 cm. The incidence of malrotation after surgery may be lower than the figure given, as 10 per cent of normal adults show a discrepancy of 10” or greater in anteversion of the femoral neck (Brouwer, 1981). Inpatient stay was less than 30 days in 74 per cent of patients.
reds
Treatment
Author
Perkins traction Russell traction Cast bracing Cast bracing DC plate Interlocking nail
Buxton (1981) Anderson (1967) Sarmiento and Latta (1981) Hardy (1983) Magerl et al. (1979) Majkowski and Baker
Number
Shortening >2cm
Varus/valgus angulation > 5’
50 59 245 108 86 43
6% 6.7% Not given 12% 0% 13%
Not given 40% 59% 30% 9% 32%
Lnjury: the British Journal of Accident Surgery (1991) Vol. 22/No.
96
Conclusion Closed locked intramedullary nailing of femoral shaft fractures is undoubtedly a challenging technique with a learning curve. However, with the alterations in technique described, we feel that satisfactory results can be achieved even in relatively
inexperienced
hands.
References Anderson R. L. (1967) Conservative treatment of fractures of the femur. 1. Bone joint Surg. @A, 1371. Brouwer K. J. (1981) Torsional deformities after fractures of the femoral shaft in childhood. A retrospective study, 27-32 years after trauma. Acfu Orfhop. Stand. Suppl. 195. Browner B. D. (1986) Pitfalls, errors and complications in the use of locking Kiintscher nails. Qin. Orthop. 212.192. Buxton R. A. (2981) The use of Perkins’ traction in the treatment ot femoral shaft fractures. 1. &me Joint Surg. 63B, 362. Christie J., Court-Brown C., Kinninmonth A. W. G. et al. (19881 Intramedullary locking nails in the management of femoral shaft fractures. 1. Bone joint Surg. 7OB, 206. Gustilo R. B. and Anderson J. (1976) Prevention of infection in the treatment of one thousand and twenty-five fractures of long bones. 1. Bone Joint Surg. .58A, 453.
2
Hardy A. E. (1983) The treatment of femoral fractures by cast-brace application and early ambulation. J. Bone Joint Surg. 65A, 56. Kempf I., Grosse A. and Beck G. (1985) Closed locked intramedullary nailing. Its application to comminuted fractures of the femur. J. Bone ]oinf Surg. 6 7A, 709. Klemm K. W. and Bomer M. (1986) Interlocking nailing of complex fractures of the femur and tibia. Clin. Or&p. 212,89. Magerl F., Wyss A., Brunner C. et al. (1979) Plate osteosynthesis of femoral shaft fractures in adults. Clin. Orfhop. 138,62. Sarmiento A. and Latta L. L. (1981). Closed Fttncfional Treattnent of Fracfures. Berlin Heidelberg New York: Springer-Verlag, 336. Winquist R. A., Hansen S. T. Jr and Clawson D. K. (1984) Closed intramedullary nailing of femoral fractures. J, Bone Joint Surg. 66A, 529. Wiss D. A., Fleming C. H., Matta J. M. et al (1986) Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. Clin. Orthop. 212,35.
Paper accepted
10 August
1990.
Requesfs for reprints should be addressed to: R. S. Majkowski FRCS, 50 King George Close, Charlton Park, Cheltenham, Gloucestershire GL53 7RW, UK.