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Intramedullary femoral nailing: removing the nail improves subjective outcome
Injury, Int. J. Care Injured 33 (2002) 247– 249 www.elsevier.com/locate/injury
Intramedullary femoral nailing: removing the nail improves subjective outcome A.D. Toms *, R.L. Morgan-Jones, R. Spencer-Jones North Staffordshire Royal Infirmary, Princes Road, Hartshill, Stoke-on-Trent, Staffordshire ST4 7LN, UK Accepted 17 August 2001
Abstract Intramedullary nailing has become an established treatment for femoral fractures. We reviewed the subjective and objective outcome of locked intramedullary nailing since its introduction to our unit in 1988. The outcome was assessed subjectively using the Short Form 36 (SF 36) health questionnaire and objectively by clinical, radiological and case note review. From 1988 to 1995, 220 intramedullary femoral nails were inserted at the North Staffordshire Royal Infirmary. Of these we were able to match the SF 36 questionnaire and case review of 91 patients. Fifty-six patients were male and 35 female with an average age of 40. Acute trauma accounted for 86 cases (six with an injury severity score \ 15 and seven open injuries). There was a 24% incidence of minor complications; there were no deep infections and no major complications. All cases recorded subjective scores within the normal range but 34 symptomatic patients who had their femoral nails removed (mainly for persistent pain or prominent metalwork) recorded noticeably higher scores in all eight assessment areas. Intramedullary nailing for femoral fractures is a technically demanding procedure and results in both a good objective and subjective outcome. It is associated with a low rate of major complications but a relatively high rate of minor complications. We conclude that the removal of intramedullary femoral nails is justified in symptomatic patients. It results in an improved subjective outcome and has a low complication rate. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction
2. Method
Femoral shaft fractures are a major source of morbidity. The majority of patients sustain a violent force to create the fracture such as a road traffic accident or a fall from height. Intramedullary (IM) nailing of femoral fractures is the treatment of choice in adults. Its advantages include a small surgical exposure, preservation of periosteal vasculature, predictable restoration of length and alignment, early mobilisation and weight bearing, a high union rate and low rate of infection. Little is known, however, about the subjective outcome of IM femoral nailing. The aim of our study was to review subjective and objective outcomes in patients who had undergone IM femoral nailing at our unit, the North Staffordshire Royal Infirmary (NSRI), since its introduction in 1988.
Patients were reviewed to establish an objective outcome in terms of technical and clinical success. In all cases, X-ray films and clinical notes were reviewed to assess nail placement, restoration of femoral length and alignment and implant failure. The incidence of postoperative complications and the need for further operative intervention was also established. Patients identified during the study period were asked to complete a postal survey to measure the subjective outcome using the SF 36 health questionnaire. Scoring was then performed as described in the Medical Outcomes Trust SF 36 health survey scoring manual. The SF 36 health questionnaire measures generic health concepts and is relevant across age, disease and treatment groups. A score is obtained from the standardised response to 36 questions covering eight generic health groups, four physical and four mental. The higher the score the better the outcome.
* Corresponding author. Present address: 35 Simpsons Walk, Horsehay, Telford, Shropshire TF4 2PA, UK. Tel.: + 44-1952-504326; fax: + 44-1746-785-219.
0020-1383/02/$ - see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 1 4 5 - 0
A.D. Toms et al. / Injury, Int. J. Care Injured 33 (2002) 247–249
248
3. Results Between 1988 and 1995, a total of 220 locked IM femoral nails were inserted at the North Staffordshire Royal Infirmary. Of these 50 had died of unrelated medical conditions and 79 were untraceable, due to being outside the normal catchment area of the NSRI. We were able to review case notes and X-rays, and complete an SF 36 health questionnaire on the remaining 91 patients. Of these 91 patients, 56 were male and 35 female with an average age of 39.5 years. The mean follow-up was 45.7 months (range 36–81 months). Eighty-six injuries resulted from acute trauma and five from pathological fractures. Road traffic accidents accounted for 48 (56%) and 17 (20%) resulted from a fall from height. Only five patients (6%) had an injury severity score (ISS)\ 15. Twenty-five (27%) had an ISS between 10 and 15, and 61 (67%) had an ISSB10. Of the study group only seven (8%) were open femoral fractures. Consultants or senior registrars inserted 68 (75%) of the femoral nails, whilst the remaining 23 (25%) were inserted by registrars or staff grade surgeons. The commonest implant used was the Biomet femoral nail in 71 patients (78%). A reconstruction nail was used in nine patients (10%) and the remainder were either Russell– Taylor or A.O. Universal. The overall complication rate was 24%. Four patients had non-fatal pulmonary emboli and two had an isolated DVT. All diaphyseal fractures united, although two patients required exchange nailing for delayed union. For the purpose of this study, delayed union was defined as the failure to unite at six months from initial IM nailing. One patient with a concurrent intracapsular femoral neck fracture treated with a reconstruction nail went on to non-union the femoral neck. This patient required nail removal prior to a total hip replacement. No deep infection occurred in the study group although there were two superficial infections, which resolved with appropriate antibiotic therapy. Four patients had a malunion, three of these were rotational and the fourth failed to regain the original femoral length. None of these patients required further surgery to correct the malunion. There were two nail breakages
but both fractures united without further surgery. Only one interlocking screw was seen to break. Minor heterotopic ossification was seen in four patients. Post-operative haematomas occurred in two patients but were managed conservatively. Femoral nails were removed in 34 patients (37%). The commonest reason for removal was persistent femoral pain or prominent metalwork in 14 patients. Three more patients had femoral nails removed prior to a total hip replacement. The reason for nail removal in the remaining patients was not specified and was assumed to be due to surgeon or patient preference. Subjective outcome as measured by the SF 36 health questionnaire revealed that at the follow-up all patients were within normal parameters for a normal healthy population for all eight generic health groups. However, after the IM femoral nail removal the physical and mental components both improved, compared with patients in whom nails were left in situ (Table 1). Unfortunately, these findings did not reach statistical significance due to the small number of patients and wide scatter of SF 36 scores.
4. Discussion Complications following IM femoral nailing are not uncommon [1– 5] and a satisfactory result, with return to normal activities is not always guaranteed. The literature regarding the outcome of femoral nailing has concentrated on defining success in terms of time to union and the technical and post-operative complications [6– 11]. Subjective evaluation is an important part in the assessment of outcome and previous authors have emphasised the use of broader outcome measures [12,13] particularly in trauma [14,15], where the use of patient orientated assessment has not been widely adopted. The SF 36 health questionnaire is an outcome scoring system developed to measure generic health concepts and is relevant across age, disease and treatment groups. It provides a comprehensive, psychometrically sound and efficient way to measure health from the patients’ point of view. The SF 36 outcome score is an
Table 1 SF 36 scoring categories comparing patients with a nail in situ vs. patient scores following nail removal Physical categories Nail in situ Nail removed
Physical function 55.8 71.6
Physical role 50.4 82.2
Body pain 49.9 67.1
General health 56.6 64.9
Vitality 50.9 62.5
Social function 63.3 78.8
Emotional role 61.9 88.7
Mental health 64.8 72.1
Mental categories Nail in situ Nail removed
A.D. Toms et al. / Injury, Int. J. Care Injured 33 (2002) 247–249
internally validated method of accurately assessing the outcome in diverse patient groups [16– 19]. It has been validated for the data collected by post and telephone interviews [20] and has been used in the outcome assessment following a variety of conditions including chronic lung disease [21], heart valve replacement [22] and hip arthroplasty [23]. There is a lack of data on patient orientated outcomes following musculoskeletal trauma and to date there are no published reports of outcomes following long bone fractures using the SF 36 health questionnaire. Our study shows that good subjective outcomes as measured by the SF 36 following IM femoral nailing, with patients returning scores within normal parameters for adults of working age [24], and objectively a good outcome can be expected in majority of the patients. We have also shown a high rate of minor complications but a low rate of major complications, irrespective of surgeon grade. As femoral nail removal is not without morbidity it has been recommended that only symptomatic patients should undergo nail removal [25]. We support this recommendation, although our data suggests that following nail removal, subjective outcome of both physical and mental component scores (SF 36) may improve.
References [1] Braten M, Terjesen T, Rossovoll I. Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurements of anteversion angles in 110 patients. J Bone Jt Surg 1993;75B:799 – 803. [2] Steinberg GG, Hubbard C. Heterotopic ossification after femoral intramedullary rodding. J Orthop Trauma 1993;7:536 – 42. [3] Simonian PT, et al. Iatrogenic fractures of the femoral neck during closed nailing of the femoral shaft. J Bone Jt Surg 1994;76B:293 – 6. [4] O’Malley DE, et al. Femoral head avascular necrosis associated with intramedullary nailing in an adolescent. J Paediatr Orthop 1995;15:21 – 3. [5] Tornetta P, Ritz G, Kantor A. Femoral torsion after interlocked nailing of unstable femoral fractures. J Trauma 1995;38:213 – 9. [6] Benirschke SK, et al. Closed interlocking nailing of femoral shaft fractures: assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review. J Orthop Trauma 1993;7:118 –22.
249
[7] Shepherd LE, Shean CJ, Gelais ID, Lee J, Carter VS. Prospective randomised study of reamed versus unreamed femoral intramedullary nailing: an assessment of the procedures. J Orthop Trauma 2001;15(1):28 – 33. [8] Brumback RJ, et al. Intramedullary nailing of open fractures of the femoral shaft. J Bone Jt Surg 1989;71A:1324 – 31. [9] Tornetta P III, Tibruzi D. Reamed versus unreamed antegrade femoral nailing. J Orthop Trauma 2000;14(1):15 – 9. [10] Abbas D, Faisal M, Butt MS. Unreamed femoral nailing. Injury 2000;31(9):711 – 7. [11] Cole AS, Hill GA, Theologis TN, Gibbons CLMH, Willett K. Femoral nailing for metastatic disease of the femur: a comparison of reamed and unreamed femoral nailing. Injury 2000;31(1):25 – 31. [12] Katz JN, et al. Predictors of functional outcomes after arthroscopic partial menisectomy. J Rheumatol 1992;19:1938 –42. [13] Turner JA, et al. Patient outcomes after lumbar spine fusions. J Am Med Assoc 1992;268:907 – 11. [14] MacKenzie EJ, et al. Patient orientated functional outcomes after unilateral lower extremity fracture. J Orthop Trauma 1993;7:393 – 401. [15] MacKenzie EJ, et al. Physical impairment and functional outcomes 6 months after severe lower extremity fracture. J Trauma 1993;34:528 – 39. [16] Garrett AM, Ruta DA, Abdulla MI, Buckingham JK, Russell IT. SF-36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? Br Med J 1993;306:1440 – 4. [17] Jenkinson C, Wright L, Coulter A. Criterion validity and reliability of the SF-36 in a population sample. Quality Life Res 1994;3:7 – 12. [18] McHorney CA, Ware JE, Lu JF, Sherbourne CD. The MOS 36 item short-form Health Survey (SF-36): tests of data quality, scaling assumptions and reliability across diverse patient groups. Med Care 1994;32:40 – 66. [19] Ware JE, Kosinski M, Keller SD. SF-36 physical and mental health summary scales: a user’s manual. Boston, MA: The Health Institute, New England Medical Centre, 1994. [20] McHorney CA, Ware JE, Kosinski M. Comparison of costs and quality of norms for the SF-36 survey collected by mail versus telephone interview: results from a national survey. Med Care 1994;32:551 – 67. [21] Viramontes JL, O’Brien B. Relationship between symptoms and health related quality of life in chronic lung disease. J Gen Intern Med 1994;9:46 – 8. [22] Phillips RC, Lansky DJ. Outcome management in heart valve surgery: early experience. J Heart Valve Dis 1992;1:42 –50. [23] Katz RB, et al. Comparative measurement sensitivity of short and longer health status instruments. Med Care 1992;30:917 –25. [24] Jenkinson C, et al. Short form 36 (SF-36) health survey questionnaire: normative data for adults of working age. Br Med J 1993;306:1437 – 40. [25] Miller R, et al. Removal of intramedullary rods after femoral shaft fracture. J Orthop Trauma 1992;6:460 – 3.
Intramedullary femoral nailing: removing the nail improves subjective outcome A.D. Toms *, R.L. Morgan-Jones, R. Spencer-Jones North Staffordshire Royal Infirmary, Princes Road, Hartshill, Stoke-on-Trent, Staffordshire ST4 7LN, UK Accepted 17 August 2001
Abstract Intramedullary nailing has become an established treatment for femoral fractures. We reviewed the subjective and objective outcome of locked intramedullary nailing since its introduction to our unit in 1988. The outcome was assessed subjectively using the Short Form 36 (SF 36) health questionnaire and objectively by clinical, radiological and case note review. From 1988 to 1995, 220 intramedullary femoral nails were inserted at the North Staffordshire Royal Infirmary. Of these we were able to match the SF 36 questionnaire and case review of 91 patients. Fifty-six patients were male and 35 female with an average age of 40. Acute trauma accounted for 86 cases (six with an injury severity score \ 15 and seven open injuries). There was a 24% incidence of minor complications; there were no deep infections and no major complications. All cases recorded subjective scores within the normal range but 34 symptomatic patients who had their femoral nails removed (mainly for persistent pain or prominent metalwork) recorded noticeably higher scores in all eight assessment areas. Intramedullary nailing for femoral fractures is a technically demanding procedure and results in both a good objective and subjective outcome. It is associated with a low rate of major complications but a relatively high rate of minor complications. We conclude that the removal of intramedullary femoral nails is justified in symptomatic patients. It results in an improved subjective outcome and has a low complication rate. © 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction
2. Method
Femoral shaft fractures are a major source of morbidity. The majority of patients sustain a violent force to create the fracture such as a road traffic accident or a fall from height. Intramedullary (IM) nailing of femoral fractures is the treatment of choice in adults. Its advantages include a small surgical exposure, preservation of periosteal vasculature, predictable restoration of length and alignment, early mobilisation and weight bearing, a high union rate and low rate of infection. Little is known, however, about the subjective outcome of IM femoral nailing. The aim of our study was to review subjective and objective outcomes in patients who had undergone IM femoral nailing at our unit, the North Staffordshire Royal Infirmary (NSRI), since its introduction in 1988.
Patients were reviewed to establish an objective outcome in terms of technical and clinical success. In all cases, X-ray films and clinical notes were reviewed to assess nail placement, restoration of femoral length and alignment and implant failure. The incidence of postoperative complications and the need for further operative intervention was also established. Patients identified during the study period were asked to complete a postal survey to measure the subjective outcome using the SF 36 health questionnaire. Scoring was then performed as described in the Medical Outcomes Trust SF 36 health survey scoring manual. The SF 36 health questionnaire measures generic health concepts and is relevant across age, disease and treatment groups. A score is obtained from the standardised response to 36 questions covering eight generic health groups, four physical and four mental. The higher the score the better the outcome.
* Corresponding author. Present address: 35 Simpsons Walk, Horsehay, Telford, Shropshire TF4 2PA, UK. Tel.: + 44-1952-504326; fax: + 44-1746-785-219.
0020-1383/02/$ - see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 1 4 5 - 0
A.D. Toms et al. / Injury, Int. J. Care Injured 33 (2002) 247–249
248
3. Results Between 1988 and 1995, a total of 220 locked IM femoral nails were inserted at the North Staffordshire Royal Infirmary. Of these 50 had died of unrelated medical conditions and 79 were untraceable, due to being outside the normal catchment area of the NSRI. We were able to review case notes and X-rays, and complete an SF 36 health questionnaire on the remaining 91 patients. Of these 91 patients, 56 were male and 35 female with an average age of 39.5 years. The mean follow-up was 45.7 months (range 36–81 months). Eighty-six injuries resulted from acute trauma and five from pathological fractures. Road traffic accidents accounted for 48 (56%) and 17 (20%) resulted from a fall from height. Only five patients (6%) had an injury severity score (ISS)\ 15. Twenty-five (27%) had an ISS between 10 and 15, and 61 (67%) had an ISSB10. Of the study group only seven (8%) were open femoral fractures. Consultants or senior registrars inserted 68 (75%) of the femoral nails, whilst the remaining 23 (25%) were inserted by registrars or staff grade surgeons. The commonest implant used was the Biomet femoral nail in 71 patients (78%). A reconstruction nail was used in nine patients (10%) and the remainder were either Russell– Taylor or A.O. Universal. The overall complication rate was 24%. Four patients had non-fatal pulmonary emboli and two had an isolated DVT. All diaphyseal fractures united, although two patients required exchange nailing for delayed union. For the purpose of this study, delayed union was defined as the failure to unite at six months from initial IM nailing. One patient with a concurrent intracapsular femoral neck fracture treated with a reconstruction nail went on to non-union the femoral neck. This patient required nail removal prior to a total hip replacement. No deep infection occurred in the study group although there were two superficial infections, which resolved with appropriate antibiotic therapy. Four patients had a malunion, three of these were rotational and the fourth failed to regain the original femoral length. None of these patients required further surgery to correct the malunion. There were two nail breakages
but both fractures united without further surgery. Only one interlocking screw was seen to break. Minor heterotopic ossification was seen in four patients. Post-operative haematomas occurred in two patients but were managed conservatively. Femoral nails were removed in 34 patients (37%). The commonest reason for removal was persistent femoral pain or prominent metalwork in 14 patients. Three more patients had femoral nails removed prior to a total hip replacement. The reason for nail removal in the remaining patients was not specified and was assumed to be due to surgeon or patient preference. Subjective outcome as measured by the SF 36 health questionnaire revealed that at the follow-up all patients were within normal parameters for a normal healthy population for all eight generic health groups. However, after the IM femoral nail removal the physical and mental components both improved, compared with patients in whom nails were left in situ (Table 1). Unfortunately, these findings did not reach statistical significance due to the small number of patients and wide scatter of SF 36 scores.
4. Discussion Complications following IM femoral nailing are not uncommon [1– 5] and a satisfactory result, with return to normal activities is not always guaranteed. The literature regarding the outcome of femoral nailing has concentrated on defining success in terms of time to union and the technical and post-operative complications [6– 11]. Subjective evaluation is an important part in the assessment of outcome and previous authors have emphasised the use of broader outcome measures [12,13] particularly in trauma [14,15], where the use of patient orientated assessment has not been widely adopted. The SF 36 health questionnaire is an outcome scoring system developed to measure generic health concepts and is relevant across age, disease and treatment groups. It provides a comprehensive, psychometrically sound and efficient way to measure health from the patients’ point of view. The SF 36 outcome score is an
Table 1 SF 36 scoring categories comparing patients with a nail in situ vs. patient scores following nail removal Physical categories Nail in situ Nail removed
Physical function 55.8 71.6
Physical role 50.4 82.2
Body pain 49.9 67.1
General health 56.6 64.9
Vitality 50.9 62.5
Social function 63.3 78.8
Emotional role 61.9 88.7
Mental health 64.8 72.1
Mental categories Nail in situ Nail removed
A.D. Toms et al. / Injury, Int. J. Care Injured 33 (2002) 247–249
internally validated method of accurately assessing the outcome in diverse patient groups [16– 19]. It has been validated for the data collected by post and telephone interviews [20] and has been used in the outcome assessment following a variety of conditions including chronic lung disease [21], heart valve replacement [22] and hip arthroplasty [23]. There is a lack of data on patient orientated outcomes following musculoskeletal trauma and to date there are no published reports of outcomes following long bone fractures using the SF 36 health questionnaire. Our study shows that good subjective outcomes as measured by the SF 36 following IM femoral nailing, with patients returning scores within normal parameters for adults of working age [24], and objectively a good outcome can be expected in majority of the patients. We have also shown a high rate of minor complications but a low rate of major complications, irrespective of surgeon grade. As femoral nail removal is not without morbidity it has been recommended that only symptomatic patients should undergo nail removal [25]. We support this recommendation, although our data suggests that following nail removal, subjective outcome of both physical and mental component scores (SF 36) may improve.
References [1] Braten M, Terjesen T, Rossovoll I. Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurements of anteversion angles in 110 patients. J Bone Jt Surg 1993;75B:799 – 803. [2] Steinberg GG, Hubbard C. Heterotopic ossification after femoral intramedullary rodding. J Orthop Trauma 1993;7:536 – 42. [3] Simonian PT, et al. Iatrogenic fractures of the femoral neck during closed nailing of the femoral shaft. J Bone Jt Surg 1994;76B:293 – 6. [4] O’Malley DE, et al. Femoral head avascular necrosis associated with intramedullary nailing in an adolescent. J Paediatr Orthop 1995;15:21 – 3. [5] Tornetta P, Ritz G, Kantor A. Femoral torsion after interlocked nailing of unstable femoral fractures. J Trauma 1995;38:213 – 9. [6] Benirschke SK, et al. Closed interlocking nailing of femoral shaft fractures: assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review. J Orthop Trauma 1993;7:118 –22.
249
[7] Shepherd LE, Shean CJ, Gelais ID, Lee J, Carter VS. Prospective randomised study of reamed versus unreamed femoral intramedullary nailing: an assessment of the procedures. J Orthop Trauma 2001;15(1):28 – 33. [8] Brumback RJ, et al. Intramedullary nailing of open fractures of the femoral shaft. J Bone Jt Surg 1989;71A:1324 – 31. [9] Tornetta P III, Tibruzi D. Reamed versus unreamed antegrade femoral nailing. J Orthop Trauma 2000;14(1):15 – 9. [10] Abbas D, Faisal M, Butt MS. Unreamed femoral nailing. Injury 2000;31(9):711 – 7. [11] Cole AS, Hill GA, Theologis TN, Gibbons CLMH, Willett K. Femoral nailing for metastatic disease of the femur: a comparison of reamed and unreamed femoral nailing. Injury 2000;31(1):25 – 31. [12] Katz JN, et al. Predictors of functional outcomes after arthroscopic partial menisectomy. J Rheumatol 1992;19:1938 –42. [13] Turner JA, et al. Patient outcomes after lumbar spine fusions. J Am Med Assoc 1992;268:907 – 11. [14] MacKenzie EJ, et al. Patient orientated functional outcomes after unilateral lower extremity fracture. J Orthop Trauma 1993;7:393 – 401. [15] MacKenzie EJ, et al. Physical impairment and functional outcomes 6 months after severe lower extremity fracture. J Trauma 1993;34:528 – 39. [16] Garrett AM, Ruta DA, Abdulla MI, Buckingham JK, Russell IT. SF-36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? Br Med J 1993;306:1440 – 4. [17] Jenkinson C, Wright L, Coulter A. Criterion validity and reliability of the SF-36 in a population sample. Quality Life Res 1994;3:7 – 12. [18] McHorney CA, Ware JE, Lu JF, Sherbourne CD. The MOS 36 item short-form Health Survey (SF-36): tests of data quality, scaling assumptions and reliability across diverse patient groups. Med Care 1994;32:40 – 66. [19] Ware JE, Kosinski M, Keller SD. SF-36 physical and mental health summary scales: a user’s manual. Boston, MA: The Health Institute, New England Medical Centre, 1994. [20] McHorney CA, Ware JE, Kosinski M. Comparison of costs and quality of norms for the SF-36 survey collected by mail versus telephone interview: results from a national survey. Med Care 1994;32:551 – 67. [21] Viramontes JL, O’Brien B. Relationship between symptoms and health related quality of life in chronic lung disease. J Gen Intern Med 1994;9:46 – 8. [22] Phillips RC, Lansky DJ. Outcome management in heart valve surgery: early experience. J Heart Valve Dis 1992;1:42 –50. [23] Katz RB, et al. Comparative measurement sensitivity of short and longer health status instruments. Med Care 1992;30:917 –25. [24] Jenkinson C, et al. Short form 36 (SF-36) health survey questionnaire: normative data for adults of working age. Br Med J 1993;306:1437 – 40. [25] Miller R, et al. Removal of intramedullary rods after femoral shaft fracture. J Orthop Trauma 1992;6:460 – 3.