Locked intramedullary nailing of fractures of femur and tibia

Injury (1990)21, 385-388

Printed in Great Britain

Locked intramedullary and tibia

385

nailing of fractures of femur

G. Folleris, A. Ahlo, K. Strsmsee, E. Ekeland and B. 0. Thoresen Orthopaedic

Service, Ullevaal Hospital, University

of Oslo, Oslo, Norway

The rt5ults of 194 consecuh’veinterlocking nailings for 95fractares in the tibia and 99 fracturesin thefemur with a median observation time of 22 months are presented. Three fractures were not consolidated radiologcally at follow-up; three deep infections were recorded, all of which healed. Shortening > I cm was recordedin I 7 fractures 5” in 2 I, and angular malaligment I> 5” occurred in I 7. Ihe end result was excellent in 121fractures,good in 41,fair in 28,and poor in 4.

Introduction The treatment of fractures in the long bone shafts of the lower extremity has varied considerably during the last 30 years. In the femur, the tendency is towards operative treatment (Kessel and Schweiberer, 1989). Intramedullary nailing has proved to be a safe method of treating fractures in the middle third of the femur and tibia. Locking of the nail with screws has extended the indications for intramedullary nailing, and it is now possible to use the interlocking nail to treat nearly all shaft fractures except the most proximal and distal ones (Klemm and Schellmann, 1972; Kempf et al., 1985). In the femur we have used the interlocking nail as the standard fixation device, except in the condylar area of the bone (Thoresen et al., 1985). In the tibia, the nail has been used in irreducible tibial fractures, unstable fractures, fractures with a tendency to shortening and in multiple injuries (Ekeland et al., 1988). The nail is used in the femur in open fractures grades 1-3 and in the tibia we have used it in grades I and 2, the grade 3 open fractures being treated with external fixation. All the femoral shaft fractures and 21 per cent of all our tibial shaft fractures have been treated operatively. In ali cases the Grosse-Kempf interiocking nail (Kempf et al., 1978) for tibia or femur have been used. This paper reports the collective results of all patients operated on using the interlocking nail.

Patients and methods We studied all consecutive interlocking in the period December 1979 to August was undertaken in two time periods; in The patients were seen in the outpatient 0 1990 Butterworth-Heinemann 0020/1383/90/060385~4

Lttl

nailings performed 1986. This survey 1985 and in 1988. department, and a

detailed protocol concerning the history, operation, and progress after the operation was completed for each patient; a physical examination was carried out and the results recorded; the radiographs were reviewed. In the final radiograph the varus, valgus, antecurvation, and retrocurvation angle at the fracture site was measured. Clinically, the shortening, external and internal rotation at the fracture site were recorded. The rotatory deformity at the fracture site of the femur was measured as the difference in rotation between the operated and unoperated hip. The torsion at the fracture site of the tibia was measured as the difference in foot angle between the non-operated and operated side, with the patient in the sitting position with the lower legs hanging. The results were fed to a computer (ND 500) and analysed. Some statistical analyses were carried out using a standard statistical microcomputer program (Exploring Statistics with the IBM PC). A total of 208 fractures in 188 patients underwent operation; 14 were excluded from the analysis. The reasons for the exclusion were: nine had incomplete follow-up, three died from unrelated causes, one had a new fracture in the operated femur and one had a disarticulation of the knee due to a severe laceration, of the lower leg, There were 196 fractures left for analysis in patients aged from 13 to 90 years, with a median age of 31 years. There were 99 femoral and 95 tibial fractures. Of these patients, 115 (59 per cent) were males, and 79 (41 per cent) were females. The accident causing the fracture occurred in road traffic in 110 cases, in connection with sport in 21 cases, in 28 cases at home, and in 7 cases at work. The remaining 28 cases were caused by miscellaneous types of injury. There were 162 closed fractures, 19 were open grade 3, 11 were open grade 2, and 2 were open grade 3. Figure I shows the localization of the open fractures. There were 117 fractures caused by high-energy trauma, and 77 were caused by low-energy trauma. The fracture type was transverse or short oblique in 72 patients, long oblique (fracture line longer than two bone diameters) in 52, comminuted in 63 and ‘segmental in 7 patients. The femur and tibia were divided into sixths, and the fractures were located to one sixth part, using the most condylar-close part of the fracture line as the locating

Injury: the British Journal of Accident Surgery (1990)Vol. Zl/No.6

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I

Total

0Den fractures

4

I

38

2

30

3

58

13

56

12

Figure I. Tibia and femur are divided into 6ths, and the total number of fractures occurring in each zone are listed in the first column; the number of open fractures are listed in the second column.

criterion (FigureI). In 112 patients the fracture was their only injury, 15 patients had head injury, 17 had another fracture, and 44 were multiply injured. A total of 110 fractures were nailed primarily (within 24 h of injury); 79 fractures had a short period of non-operative treatment before the operation, of which 23 had casts and 56 had skeletal traction. Five fractures were plated before the nailing procedure. A total of 180 fractures were nailed without opening the fracture site and 14 with an open technique; the latter were mostly due to removal of failed osteosynthesis material. Statical nailing (inserting the screws in both the proximal and distal holes of the nail) was performed in 75 cases, dynamical nailing in 119 cases, 37 with proximal locking and 82 with distal locking. There were 105 fractures considered stable enough for immediate weight bearing, and 89 were considered to be sufficiently stable for exercises without weight bearing. External support with a cast for a short period was required in 5 cases. The femoral nailings were performed in the supine position on a fracture table. The fractured femur was extended and adducted. The fracture was preferably reduced by closed means, the marrow cavity was opened through a longitudinal incision cranial to the greater trochanter. The medullary cavity was reamed to a diameter 1 mm larger than the nail diameter and the nail inserted. The operation was monitored with an image intensifier. In the tibia the patient was positioned supine on the fracture table with a support under the distal part of the femur with the knee flexed 90”. A temporary calcaneal traction pin was used. The fracture was reduced and the nailing performed via a longitudinal incision through the patellar ligament. All except four nailings were performed without opening the fracture site. The marrow cavity was reamed to good cortical bone contact 1 mm above the nail diameter, and the nail inserted. The proximal locking was performed using an aiming device connected to the nail, the distal targeting was done manually (Skjeldal and Bakke, 1987).

Results The patients were examined at a median time of 22 months (range 6-97 months) after the primary operation. The median operation time was 70 min (range 30-200 min). Eight intraoperative complications were recorded. In five cases the comminution of the fracture increased, mostly owing to dislocation of an incomplete butterfly fragment. In one case the intramedullary reamer was stuck in the femur; a 1Ocm longitudinal osteotomy was necessary to solve the problem. One femoral neck fracture occurred, and additional screw fixation resulted in uneventful healing. In one tibia, one of the proximal screws failed to hit the hole in the nail but without ill effects for the patient. One patient with a tibial fracture had a concomitant vascular injury, the artery was repaired, and a prophylactic fasciotomy was performed. In two other patients with tibial fractures a compartment syndrome developed. In one patient the condition was recognized and a fasciotomy performed, in the other the diagnosis was delayed, resulting in a moderate short foot syndrome. In the postoperative period four superficial (two in the femur, two in the tibia) and three deep infections (all in the tibia) were recorded. All the superficial and two of the deep infections healed after antibiotic therapy. In the last case with deep infection in the tibia, the drainage ceased after removal of the nail. The end results of the infected fractures were five excellent and two good. One patient had to be reoperated on for a severe external rotatory malalignment. In five patients a supplementary cast had to be used. The median time to full weight bearing was 45 days (range l-180 days). The median time from operation to return to work was only recorded in the last period (90 patients), and was 13 weeks (range l-90 weeks). At follow-up 140 patients (72 per cent) were pain free, 52 (26 per cent) had slight pain, and 2 (I per cent) had severe pain. Only 18 referred their pain to the fracture site, the others referred the pain to other regions. The working capacity was unchanged in 158 patients; 23 patients claimed that it was reduced after the fracture; the remainder (13) were not sure what to answer. The ability to participate in sports was unchanged in 141 patients (72 per cent), partially reduced in 33 (17 per cent), severely reduced in 11 (6 per cent) and abolished in 9 (5 per cent). The fracture was considered healed if a callus of cortical density bridged most of the fracture site. Judged from the radiographs, 188 had a healed fracture; in three the fracture line was still visible, one patient had a pseudarthrosis, and two had missing values (one death at 3 months, two missing). The median healing time was 14 weeks in the whole series; in the tibia it was 15 weeks and in the femur it was 13 weeks. Shortening The shortening of the operated bone was O-I cm in 175 cases, 2 cm in six, 3 cm in four, and 6 and 9 cm in one case. Angular malalignment Varus O-3” was recorded in 175 cases, 4-5” in five cases, and 6-10” in nine cases. Valgus O-3” was recorded in 176 cases, 5” in four cases and 6-9” in eight cases. Antecurvation 0-5” was recorded in 182 cases, 6-9” in 6 cases. Retrocurvation O-5” was measured in 181 cases, 6-10” in five cases, and X1-21” in three cases.

FoIlerAset al.: Locked intrameduhry nailing

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2

3

4

387

5

PosItIonof molposltion of the bone

6

Figure 2. Total number of malpositions

including shortenings in each 6th part are divided with the total number of fractures in the same 6th part. The quotient represents the risk of malposition in each 6th part.

Rotatory malalignment Internal rotation O-5” was recorded in 187 cases, 10” in three, and 20” in one case. External rotation 0-5” was measured in 172 cases, 6-10” in nine, 15” in six, 20° in one, and 40” in one case. The different malalignments were split in two groups, one occurring in the first period of nailing (1979-1983) and those occurring in the period 1984-1986. There were no significant differences in the frequencies of malalignments and shortening between these periods (x2 test). In order to locate the most difficult zone of the bone (where most malpositions occurred) the total number of malpositions, including the shortenings, were counted for each sixth part of the bones. This number was divided by the total number of fractures in the same zone. The results are shown in Figure 2.

Joint motion The passive joint mobility was tested in all operated legs. In the patients operated on for femoral fracture (N=99), 94 had flexion in the hip greater than 120”; five had between 90” and x20”, one patient had a flexion contracture between 10” and 20”, the rest had no flexion contracture. Knee flexion was greater than 120” in 9.5 patients, four had flexion between 90” and 120’. No patient had extension deficit > 10”. In the tibial fractures (N= 95), 85 patients could flex the knee more than 12O”, four had flexion between 90 and 120”. Nine patients had a 1O-30” reduction in dorsiflexion of the ankle, four had a similar reduction in plantar flexion, and six had subtalar movement reduced by one-half. One short foot syndrome was among those with reduced ankle-foot motion. The end result was evaluated according to the criteria in Table I. The results are shown in Table II. Two poor results

were recorded in the femur: one geriatric patient with a 9cm shortening, and one with a 40” external rotatory malalignment. The malalignment was corrected at a later operation. In the tibia, one patient had a new fracture with breakage of the nail proximally. He was treated initially with plaster and later with plating and bone grafting. One patient developed a non-union with breaking of the nail. The fracture was treated with removal of the nail and plating with cancellous grafts. Both fractures healed, but they were classified as poor results due to failure of the method.

Discussion Treatment of femoral fractures in adults by non-operative methods demands long hospital stay and frequently results in malalignment (Stryker et al., 1970; Johnson and Greenberg, 1987). Most orthopaedic surgeons agree that the treatment of choice is operative (Huckstep, 1988). In the tibia our policy has been to treat most fractures non-operatively. In unstable fractures, in multiply injured patients and in cases where non-operative treatment has failed, we find operative treatment indicated and use the interlocking nail in ail cases except open grade 3 fractures. The interlocking nail has the technical ability to give the fracture the necessary stability even when the fracture occurs near the metaphyses of the bone. It can also secure length in comminuted fractures (Kempf et al., 1978). It is far more versatile than the traditional intramedullary nail, covering almost all fractures in the shaft of the femur and tibia. In our study, only three cases (1.5 per cent) had a visible fracture line at the follow-up examination. This is better than other series (Wihlborg, 1987; Brumbach et al., 1988) where the frequency of non-union is higher. A major concern in operative treatment of fractures is infection. This series, including 32 open fractures and 117 high-energy fractures, with only one long-lasting deep infection (0.5 per cent), compares well with other series of plating (Burwell, 1971; Loomer et al., 1980) and flexible medullary wires (Hasenhuttl, 1981). The nail permitted immediate weight bearing in 105 fractures and active exercises in 84 cases. The mobility of the hip and knee were near normal, and in the ankle only nine patients had reduction in joint movement. The return to work was rapid and most patients returned to their prefracture activity level. We have analysed the frequency of malalignment and shortening in the two periods. In the first period, most of the operations were carried out by the authors. In the last period

Table I. The results are graded excellent, good, fair and poor. The criteria for result-evaluation

are given

Derangement Varus or valgus Ante- or recurvatum Internal rotation External rotation Shortening Knee flexion Knee ext. deficit Ankle dorsiflexion Ankle plantar flexion Foot motion (fraction of normal) Pain or swelling

Excellent 3 5 5 IO 1 cm z-120 5 >20 >30 516 None

Good 5 IO IO 15 2cm 720 IO 20 30 213

Fair IO 15 15 20 3cm 90 15 ;: l/3 Significant

Poor >I0 >I5 >15 >20 r3cm (90 >I5
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.6

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Table II. The results after treating 196 fractures in femur and tibia

with the Grosse-Kempf interlocking nail Grading

Number of fractures

Percent of total

Excellent Good Fair Poor

121 41 28 4

62 21 14 2

were carried out by many surgeons, both senior and junior. The frequency of malalignments and shortening did not significantly differ between the periods. It is concluded that the method is robust and can be utilized with good results by surgeons without much experience in the method. Early in our experience we tended to prefer dynamic nailing. Soon some malalignments (shortening, rotatory malalignments) started to occur, and based on this experience we now recommend the use of static nailing if there is a possibility of shortening or rotatory instability. The static nailing can in some cases delay healing owing to distraction at the fracture site. In those fractures one can remove the screws (dynamize the nail) at a time when the risk of malalignment is minimal, usually at 2-4 months. Our results compared with other methods of osteosynthesis (Burwell, 1971; Steen Jensen et al., 1977; Loomer et al., 1980; Hasenhuttl, 1981) and are satisfactory such that we will continue using the interlocking nail in fractures of the shaft of the femur and tibia, when operative treatment is indicated. the operations

References Alho A., Ekeland A. and Stromsoe K. et al. (1990) Locked

Ekeland A., Thoresen B. O., Alho A. et al. (1988) Interlocking intramedullary nailing in the treatment of tibial fractures. A report of 45 cases. Clin. orthop. 178, 64. Hasenhuttl K. (1981) The treatment of unstable fractures of the tibia and fibuIa with flexible medullq wires. 1, BoneJoint Surg. 63A, 921.

Huckstep R. L. (1988) Major lower limb trauma. Curr. Orthop. 2,l. Johnson K. D. and Greenberg M. (1987) Comminuted femoral shaft fractures. Orfhop. Clin. Norfh. Am. IS, 133. Klemm D. and Schellmann W. D. (1972) Dynamische und statische Verriegelung des Marknagels. Mschr Unnfallkilktmde,568. Kempf I., Grosse A. and Lafforgue D. (1978) L’apport du verrouillage dans l’enclouage centro-medullaire des OS longs. Rev. Chir. Orthop. 64,635. Kempf I., Grosse A. and Beck G. (1985) Closed locked intramedullary nailing. Its application to cornminuted fractures of the femur. 1. BoneJoint .!%a. 67A, 709.

Kessel S. B. and Schweiberer L. (1989) Fortschritt und Wandel in der behandlung von Schaftfrakturen von Femur und Tibia. Orfhopaede18,187. Loomer R. L., Meek R. and De Sommer F. (1980) Plating of femoral shaft fractures: the Vancouver experience. J. Trauma 20,1038. SkjeldaI S. and Bakke S. (1987) Interlocking meduIIary nails radiation doses in distal targeting. Arch. Orthop. Trauma Surg.

106,17!+181. Steen Jensen J., Wang Hansen F. and Johansen J. (1977) Tibial shaft fractures. A comparison of conservative treatment and internal fixation with conventional plates or A0 compression plates. Acta orfhop. %x&. 48,204. Stryker W. S., Fussell M. E. and West H. D. (1970) Comparison of the results of operative and non-operative treatment of &aphyseal fractures of the femur. 1. BoneJoint Surg. 52A, 815. Thoresen B. O., Alho A., Ekeland A. et al. (1985) Interlocking intramedullary nailing in femoral shaft fractures: a report of forty-eight cases. J. BoneJoint Surg. 67A, 1313. Wihlborg 0. (1987) Retrospektiv studie av tibiaskaftfrakturer. Slutresultatet &mst hos konservativt behandIade. Ulcartidningen 14‘1154.

intramedullary nailing in displaced tibial shaft fractures. J. Bone Joint Surg. 72B (in press).

Paper accepted

29 January

1990.

Burwell H. N. (1971) Plate fixation of tibial shaft fractures. ]. Bone joint Surg. 53B, 258.

Brumbach Robert J, Uwagie-Ero S., Lakatos Ronald P. et al. (1988) Intramedullary nailing of femoral shaft fractures. 1, Bone Joint Surg. 7OA, 1453.

Requestsfor reprintsshouti be a&ressed to: GUNW Folleris, Sophies Minde Orthopaedic Hospital, Trondheimsv. 132, N-0560 Oslo 5, Norway.