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The Marchetti–Vicenzi elastic locked nail for the treatment of femoral shaft fractures: a review of 100 consecutive cases
Injury, Int. J. Care Injured 32 (2001) 307– 312 www.elsevier.com/locate/injury
The Marchetti –Vicenzi elastic locked nail for the treatment of femoral shaft fractures: a review of 100 consecutive cases G. Anastopoulos a, Ath Tsoutsanis a, Ath Papaeliou b, K. Hatzistamatiou c, G. Babis d, A. Assimakopoulos e,* a 3, Promitheos St., 14565 Ekali, Athens, Greece 33, Pa6lou Mela St., 16233, Kareas, Athens, Greece c 55, Kianis Aktis St., 19009 Mati, Athens, Greece d 17, Solomou St., 16451 Argiroupolis, Athens, Greece e 12, Doridos St., 15562 Holargos, Athens, Greece b
Accepted 20 September 2000
Abstract A total of 100 hundred femoral fractures in 97 patients were treated with the Marchetti– Vincenzi universal bundle elastic nail; six of the fractures were open. Closed fractures were classified according to AO and Winquist; open fractures were classified according to Gustilo. A total of 91 fractures united (average 12 weeks) and six led to non-union. There were two deep and one superficial infections. In three cases, the secondary nails protruded from the anterior cortex of the femoral condyle; in two cases intraoperatively and in the third case 2 months postoperatively, due to severe osteoporosis. The cylindrical part of the nail did not fail, whereas all the secondary nails failed in one patient as well as one secondary nail in another patient at the level of the fracture; these two cases exhibited non-union. We consider the absence of distal screws the major advantage of this particular nail, followed by position of the entry point and the limited reaming. We believe that the absence of a pin guide is a disadvantage. The elasticity of the nail has a positive effect in certain cases while in other cases it acts negatively, resulting in a relatively high proportion of non-unions as in our series. Therefore our conclusion is that this nail is not appropriate for the treatment of femoral shaft fractures. © 2001 Elsevier Science Ltd. All rights reserved.
1. Introduction Attempts to treat limb shaft fractures with thin elastic nails began in the middle of the 20th Century. Lambrinudi [1] and Danis [2] used intramedullary osteosynthesis with Kirschner wires. The Rush brothers [3] designed and used successfully the nail that bears their name in femoral and tibial shaft fractures, which was probably the first organized attempt at elastic osteosynthesis. However, their nails were soon subject to severe criticism and mostly not been accepted [4]. In contrast, the Ender elastic nails have been more fortunate, and in spite of their problems are still being used for certain types of fracture [5 – 11]. The contribution made by flexible intramedullary rods to callus formation in fractures of long-bone shafts has been studied for many years [12,13]. Their numer* Corresponding author.
ous advantages, the chief of which is undoubtedly their insertion without previous reaming, are nullified in practice by their serious mechanical instability and therefore they are mostly appropriate for stable fractures. Caffiniere et al. [14] tried to deal with this weak point by locking centrally two of the four rods. In their excellent biomechanical and clinical study, they proved the importance of elastic intramedullary osteosynthesis. The Marchetti –Vincenzi elastic nail consists basically of a combination of classic locking nails (central part) and an Ender’s (peripheral part), which increases substantially the mechanical stability.
1.1. Characteristics of the nail The femoral nail has a proximal, cylindrical, tapered component, inclined laterally by 8° and threaded proximally to host the impactor, with holes for one transverse screw (Fig. 1(a)). Distally the proximal ends of
0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 1 9 4 - 7
G. Anastopoulos et al. / Injury, Int. J. Care Injured 32 (2001) 307–312
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the five or six secondary nails (3.5 mm in diameter) are kept firmly in place by an inner wire protruding from the proximal end of the nail. This wire keeps the nail closed by passing through the small metal loop at the end of each secondary nail. The secondary nails are elastically preloaded and, when the locking wire is removed, they will open distally (Fig. 1(b)). In other words, opening the nail is achieved simply by pulling out the wire. The femoral nail is available in one diameter of the cylindrical tapered component (13 mm) and two distal diameters, 10 and 11 mm, and in 12 lengths (from 32 to 48 cm), incrementing by 1.5 cm. The proximal transverse screw is self-tapping, has a diameter of 6.35 mm, and its length ranges from 5 to 9 cm.
2. Patients and methods Between November 1993 and December 1996, we treated 100 femoral shaft fractures in 97 patients. A total of 67 of these patients were men and 30 were women, with an average age of 31.3 years. Among these patients, 20 had multiple injuries and five of those had thoracic trauma. The main cause of the injuries was a road
accident, in 83 cases. In five patients, there was also a tibial fracture that was managed with an elastic intramedullary nail. Of the 97 patients, one patient had a Gustilo [15] grade I injury, three had grade II injuries and two grade IIIa. All fractures were classified according to AO, by which there were 38 of type A (6 A1, 3 A2, 29 A3), 51 of type B (17 B1, 21 B2, 13 B3) and 11 of type C (3 C1, 3 C2, 5 C3), whereas with classification according to the Winquist comminution there were five of type I, 22 of type II, 29 of type III and eight of type IV; three were bipolar and 33 were without comminution. Topographically, according to the AO zones, there were 13 fractures of zone I, 68 of zone II and 17 of zone III, whereas in two fractures there was more than one zone involved. At the time of initial admission of the patients to the emergency room, transkeletal traction from the femoral condyles was put in place. The average time from admission to operation was 4 days. The equipment, the placement of the patient on the orthopaedic surgical table and the reduction of the fracture were all identical to those for typical closed intramedullary nailing with a locked nail.
Fig. 1. (a) The Marchetti–Vicenzi elastic nail in locked position; (b) the nail unlocked.
G. Anastopoulos et al. / Injury, Int. J. Care Injured 32 (2001) 307–312
2.1. Operati6e technique The entry point is the tip of the greater trochanter. The guide with olive is inserted into the proximal femur and reaming follows for the first 12 cm of the bone, up to 13 mm in diameter, so that it will receive the cylindrical part of the nail. The rod bundle is introduced without previous reaming; the introduction of the nail follows. After fluoroscopic verification that the distal end of the nail has transversed the focus of the fracture, the bundle of preloaded rods is unlocked by simple traction on the locking wire. The secondary nails are opened and the nail is advanced up to 2 cm from the synovial surface of the knee. Finally, a central screw is placed through the impactor (when static nailing is performed).
2.2. Operati6e choices The indications for static or dynamic nailing remain the same. In 74 fractures, closed intramedullary nailing was performed, whereas in 26, due to difficulties in reduction and in advancing the nail afterwards, a small skin incision was made above the focus of the fracture and, with a very few detachments made with the help of the finger, we facilitated the advancement of the nail into the distal part of the fracture. Blood loss with the closed technique was 350 ml, whereas with the open technique it was 500 ml. The X-irradiation time ranged from 6 to 12 s; the average operative time was 45 min (25 – 70 min).
2.3. Postoperati6e procedures On the first postoperative day, the patient undergoes isometric exercises for the quadriceps and on the second day stands up, without loading or with a partial load, according to the type of the fracture, if his or her general condition permits. Full loading is according to the nailing type: with dynamic nailing we encourage the patient to place full loading from the first week; with static nailing the loading is related to the radiographic imaging of the visible callus. The average duration of hospitalization for isolated fractures was 8 days, whereas for patients with multiple injuries it was 17 days.
3. Results All the patients were assessed clinically and radiologically every month at least until the fractures had healed. Of 97 patients, three died from causes unconnected with the fracture. Of the 97 fractures, 91
309
healed between 8 and 19 weeks (median 12 weeks) (Fig. 2). We consider the fracture healed when the patient walks without pain, without the use of supporting aids, and if the radiographs reveal bridging callus in two projections. Six fractures progressed to non-union, five of which were hypertrophic (one was septic) and one was atrophic in an open fracture of grade II. In four of the six non-unions, open reduction had been used (P= 0.020). Five of six non-unions were managed with exchange nailing and finally healed. One non-union was managed with retention of the existing nail, which finally healed in 15 months. In all six nonunions a nail with five pins had been used (P= 0.026). Three fractures were united with varus deformity of 10°; in one of them there was a coexistent 2-cm shortening. We believe that these complications were due to inappropriate operative technique. In three patients the pins protruded from the anterior cortex. In two of them this protrusion occurred during the operation, at the moment of the advancement of the nail to the area of the femoral trochlea, whereas in the third it happened around the second postoperative month due to severe osteoporosis. There were two cases of deep infection, in one of which healing was normal with the intravenous administration of antibiotics. In the second, the infection led to a septic non-union so we proceeded to the removal of the nail, surgical debridement, placement of external osteosynthesis, and intravenous administration of antibiotics; callus formed in 3 months. A superficial infection occurring in the first postoperative month was treated by surgical debridement and the administration of antibiotics; healing occurred within 8 weeks. There were two cases of pulmonary embolism on the second to third day after injury in patients with multiple injuries, and one case of postoperative embolization in an 82-year-old woman. None of the patients died. Certain intraoperative complications were encountered. In five cases, at the stage of advancement of the nail to the distal fractured part, the protruding wired lock was positioned at an angle and it was impossible to unlock the nail. The nail was removed temporarily, the lock realigned and then repositioned. In three other cases, the lock was withdrawn during the same stage of the operation and the nail unlocked automatically before being advanced. Again, the nail was removed temporarily and was relocked and repositioned. In three more cases, during the same stage, the locking rings of some rods of the nail broke, making it impossible to reposition the nail. In all three, a new nail was used.
310
G. Anastopoulos et al. / Injury, Int. J. Care Injured 32 (2001) 307–312
Fig. 2. (a) Comminuted femoral shaft fracture (AO:C3), preoperative; (b – c) 5-month postoperative F/P radiographs showing that the fracture is consolidated.
G. Anastopoulos et al. / Injury, Int. J. Care Injured 32 (2001) 307–312
311
4. Discussion
References
After our 10-year experience in the treatment of femoral shaft fractures with locking intramedullary nails [16,17], we decided to use the Marcetti – Vicenzi elastic nail due to certain advantages which we considered favourable. Material analysis had revealed that the elastic nail offers stable osteosynthesis, maintaining the reduction performed in relation to rotation, length, and axis, and is sufficient even for comminuted fractures. A contraindication to its use is the presence of severe osteoporosis; in distal-type femoral fractures the intact part should be 8 cm from the joint. It is known that the presence of micromovement and the transfer of loads in the area of a fracture favour callus formation [18]. We believe that the elastic behaviour of the nail is a satisfactory approach to the need for this micromovement and load to transfer, which is why the average time for callus formation was shorter than with the elastic locking nails [19 – 24], both in our series (12 weeks) and in the series of the inventors of the nail [25], with a main characteristic being the formation of abundant periosseous callus. However, the 6% of non-unions in our series is unacceptably high. It seems that Marcetti – Vicenzi nails with five secondary nails do not offer the appropriate stability and that the nail is not adequate for fractures of the distal third of the femur. The outward gradient of 8° in the cylindrical part of the nail permits its introduction just lateral to the tip of the trochanter without fear of a varus deformity in cases of subtrochanteric fractures, resulting in easier access, which is of greater importance in obese patients and especially when a supine position is used. Also, the possibility of aseptic necrosis of the femoral head [26,27] and the induction of neck fracture [28 – 31] is decreased. The limited reaming in the first 12 cm of the femur decreases the duration of the operation, the blood loss and possible intraoperative complications, such as entrapment of the reamer. However, we think that the lack of pin guide for the introduction of the nail is a basic disadvantage because it is certainly easier to introduce a pin guide than the nail, which requires very good reduction of the fracture. In our series, we needed to open the fracture nailing in 26 patients (26%) due to difficulty with introducing the nail. The avoidance of distal locking, which is for many operators the most difficult stage of intramedullary nailing [32,33] and for us the basic advantage of this nail, contributes significantly to the reduction in the amount of X-irradiation and the duration of the operation. In conclusion, we believe that this elastic nail is not to be recommended for the treatment of femoral shaft fractures.
[1] Lambrinudi C. Intramedullary Kirchner wires in the treatment of fractures. Proc R Soc Med (Sect Orthop) 1940;33:153. [2] Soeur R. Intramedullary pinning of diaphysical fractures. J Bone Joint Surg 1946;28:309. [3] Rush LV. A technique for longitudinal pin fixation of certain fractures of the ulna and of the femur. J Bone Joint Surg 1939;21:619– 26. [4] Watson-Jones R, Fractures and Joint Injuries. 3rd ed. Edinbourgh: E and S. Livingstone, 1943. [5] Gabanac I, Butel I, Escoules F. Le clou fascicule. Mem Acad Chir 1964;90:524– 7. [6] Hasenhutl K. The treatment of unstable fractures of the tibia and fibula with flexible medullary wires: a review of two hundred and thirty-five fractures. J Bone Joint Surg (Am) 1981;63A:921– 31. [7] Wiss DA. Flexible medullary nailing of acute tibial shaft fractures. Clin Orthop 1986;212:122– 32. [8] Holbrook J. Swiontkowski MF, Sanders R. Treatment of open fractures of the tibial shaft. Ender nailing versus external fixations. J Bone Joint Surg (Am) 1989;71A:1231– 8. [9] Levy AS, Levitt LE, Guntler SF, Weltzer MJ. The role of Ender rodding in tibial fractures with intact fibula. J Orthop Trauma 1990;4:75– 85. [10] Whitelaw GP, Weltzer M, Nelson A, et al. Ender tools versus external fixation in the treatment of open tibial fractures. Clin Orthop 1986;253:258– 69. [11] Jahnke Ah Jr., Fry PI, Swanson KR, Watson RC, Tapper EM. Treatment of unstable tibial shaft fractures by closed intramedullary nailing with flexible (Ender type) pins, Clin Orthop 1992; 276:267– 271. [12] Hachenthal KH. Die Bundel, Nagelung Berlin: Springer, 1961. [13] Firica A, Thioanescu O, Mucichescu D, et al. Osteosynthese de femur a clous elastiques secants. Lyon Chir 1977;73:385–7. [14] Caffiniere JY, Pelisse F, Caffiniere M. Locked intramedullary flexible osteosynthesis. J Bone Joint Surg (Br) 1994;76B:778–88. [15] Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742–6. [16] Anastopoulos G, Asimakopoulos A, Exarchou E, Pantazopoulos Th. Closed interlocked nailing in comminuted and segmental femoral shaft fractures. J Trauma 1993;35(5):772– 5. [17] Anastopoulos, G, Asimakopoulos, A, Exarchou, E, Pantazopoulos Th. Ipsilateral fractures of the femur and tibia, Injury 1992; 23 (7): 439– 441. [18] Tarr RR, Wiss DA. The mechanics and biology of intramedullary fracture fixation. Clin Orthop 1986;212:10–7. [19] Winquist RA, Hansen ST, Clawson DK. Closed intramedullary nailing of femoral fractures: A report of five hundred and twenty cases. J Bone Joint Surg 1989;66A:529– 39. [20] Zuckermann JD, Veith RG, Johnson KD, Bach AW, Hansen ST, Solvik S. Treatment of unstable femoral shaft fractures with closed interlocking intramedullary nailing. J Trauma 1987;1(3):209– 18. [21] Brumback RJ, Uwagie-Ero S, Lakatos R, et al. Intramedullary nailing of femoral shaft fractures. Part II: Fracture healing with the static interlocking femoral fixation, J. Bone Surg 1988;70A:1453– 1462. [22] Alho I, Stromsoe K, Ekeland A. Locked intramedularly nailing of femoral shaft fractures. J Trauma 1991;31:49. [23] Wiss DA, Fleming CH, Matta JM, Clark D. Comminuted and rotationally unstable fractures of the femur treated with an interlocking nail. Clin Orthop 1986;212:35. [24] Kroptl A, Naglik H, Primaves Ch, Herztz H. Unreamed intramedullary nailing of femoral fractures, J Trauma 1995; 38:717– 726.
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[25] Marchetti PG, Vicenzi G, Impallomen G. A new nail for elastic intramedullary fixation in fractures and pseudoarthroses of the femur and tibia. Orthopedics 1994;2(5):403–16. [26] Mileski Ra, Gravin KL, Crosby LA. Avascular necrosis of the femoral head in an adolescent following intramedullary nailing of the femur, J Bone Joint Surg 1994; 76A:1706–1708. [27] Mohan K. The Kuntcher rod in the treatment of femoral shaft fractures. Int Surg 1971;55:431–4. [28] Bernstein SM. Fractures of the femoral shaft and associated ipsilateral fractures of the hip. Orthop Clin North Am 1974;5:799– 818. [29] Christie J, Court-Brown C. Femoral neck fracture during
.
[30]
[31]
[32] [33]
closed medullary nailing: Brief report. J Bone Joint Surg 1988;70B:670. Harper MC, Henstorf J. Fractures of the femoral neck associated with technical errors in closed intramedullary nailing of the femur. J Bone Joint Surg 1993;68A:624– 6. Riemer BL, Butterfield SL, Ray RL, Daffner RH. Clandestine femoral neck fractures with ipsilateral diaphyseal fractures. J Orthop Trauma 1993;7:443– 9. Brownwer BD, Cole JD. Current status of locked intramedullary nailing. J Orthop Trauma 1987;1:183– 95. Brumback RJ. The rationales of interlocking nailing of the femur, tibia and humerous. Clin Orthop 1996;324:292–302.
The Marchetti –Vicenzi elastic locked nail for the treatment of femoral shaft fractures: a review of 100 consecutive cases G. Anastopoulos a, Ath Tsoutsanis a, Ath Papaeliou b, K. Hatzistamatiou c, G. Babis d, A. Assimakopoulos e,* a 3, Promitheos St., 14565 Ekali, Athens, Greece 33, Pa6lou Mela St., 16233, Kareas, Athens, Greece c 55, Kianis Aktis St., 19009 Mati, Athens, Greece d 17, Solomou St., 16451 Argiroupolis, Athens, Greece e 12, Doridos St., 15562 Holargos, Athens, Greece b
Accepted 20 September 2000
Abstract A total of 100 hundred femoral fractures in 97 patients were treated with the Marchetti– Vincenzi universal bundle elastic nail; six of the fractures were open. Closed fractures were classified according to AO and Winquist; open fractures were classified according to Gustilo. A total of 91 fractures united (average 12 weeks) and six led to non-union. There were two deep and one superficial infections. In three cases, the secondary nails protruded from the anterior cortex of the femoral condyle; in two cases intraoperatively and in the third case 2 months postoperatively, due to severe osteoporosis. The cylindrical part of the nail did not fail, whereas all the secondary nails failed in one patient as well as one secondary nail in another patient at the level of the fracture; these two cases exhibited non-union. We consider the absence of distal screws the major advantage of this particular nail, followed by position of the entry point and the limited reaming. We believe that the absence of a pin guide is a disadvantage. The elasticity of the nail has a positive effect in certain cases while in other cases it acts negatively, resulting in a relatively high proportion of non-unions as in our series. Therefore our conclusion is that this nail is not appropriate for the treatment of femoral shaft fractures. © 2001 Elsevier Science Ltd. All rights reserved.
1. Introduction Attempts to treat limb shaft fractures with thin elastic nails began in the middle of the 20th Century. Lambrinudi [1] and Danis [2] used intramedullary osteosynthesis with Kirschner wires. The Rush brothers [3] designed and used successfully the nail that bears their name in femoral and tibial shaft fractures, which was probably the first organized attempt at elastic osteosynthesis. However, their nails were soon subject to severe criticism and mostly not been accepted [4]. In contrast, the Ender elastic nails have been more fortunate, and in spite of their problems are still being used for certain types of fracture [5 – 11]. The contribution made by flexible intramedullary rods to callus formation in fractures of long-bone shafts has been studied for many years [12,13]. Their numer* Corresponding author.
ous advantages, the chief of which is undoubtedly their insertion without previous reaming, are nullified in practice by their serious mechanical instability and therefore they are mostly appropriate for stable fractures. Caffiniere et al. [14] tried to deal with this weak point by locking centrally two of the four rods. In their excellent biomechanical and clinical study, they proved the importance of elastic intramedullary osteosynthesis. The Marchetti –Vincenzi elastic nail consists basically of a combination of classic locking nails (central part) and an Ender’s (peripheral part), which increases substantially the mechanical stability.
1.1. Characteristics of the nail The femoral nail has a proximal, cylindrical, tapered component, inclined laterally by 8° and threaded proximally to host the impactor, with holes for one transverse screw (Fig. 1(a)). Distally the proximal ends of
0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 0 ) 0 0 1 9 4 - 7
G. Anastopoulos et al. / Injury, Int. J. Care Injured 32 (2001) 307–312
308
the five or six secondary nails (3.5 mm in diameter) are kept firmly in place by an inner wire protruding from the proximal end of the nail. This wire keeps the nail closed by passing through the small metal loop at the end of each secondary nail. The secondary nails are elastically preloaded and, when the locking wire is removed, they will open distally (Fig. 1(b)). In other words, opening the nail is achieved simply by pulling out the wire. The femoral nail is available in one diameter of the cylindrical tapered component (13 mm) and two distal diameters, 10 and 11 mm, and in 12 lengths (from 32 to 48 cm), incrementing by 1.5 cm. The proximal transverse screw is self-tapping, has a diameter of 6.35 mm, and its length ranges from 5 to 9 cm.
2. Patients and methods Between November 1993 and December 1996, we treated 100 femoral shaft fractures in 97 patients. A total of 67 of these patients were men and 30 were women, with an average age of 31.3 years. Among these patients, 20 had multiple injuries and five of those had thoracic trauma. The main cause of the injuries was a road
accident, in 83 cases. In five patients, there was also a tibial fracture that was managed with an elastic intramedullary nail. Of the 97 patients, one patient had a Gustilo [15] grade I injury, three had grade II injuries and two grade IIIa. All fractures were classified according to AO, by which there were 38 of type A (6 A1, 3 A2, 29 A3), 51 of type B (17 B1, 21 B2, 13 B3) and 11 of type C (3 C1, 3 C2, 5 C3), whereas with classification according to the Winquist comminution there were five of type I, 22 of type II, 29 of type III and eight of type IV; three were bipolar and 33 were without comminution. Topographically, according to the AO zones, there were 13 fractures of zone I, 68 of zone II and 17 of zone III, whereas in two fractures there was more than one zone involved. At the time of initial admission of the patients to the emergency room, transkeletal traction from the femoral condyles was put in place. The average time from admission to operation was 4 days. The equipment, the placement of the patient on the orthopaedic surgical table and the reduction of the fracture were all identical to those for typical closed intramedullary nailing with a locked nail.
Fig. 1. (a) The Marchetti–Vicenzi elastic nail in locked position; (b) the nail unlocked.
G. Anastopoulos et al. / Injury, Int. J. Care Injured 32 (2001) 307–312
2.1. Operati6e technique The entry point is the tip of the greater trochanter. The guide with olive is inserted into the proximal femur and reaming follows for the first 12 cm of the bone, up to 13 mm in diameter, so that it will receive the cylindrical part of the nail. The rod bundle is introduced without previous reaming; the introduction of the nail follows. After fluoroscopic verification that the distal end of the nail has transversed the focus of the fracture, the bundle of preloaded rods is unlocked by simple traction on the locking wire. The secondary nails are opened and the nail is advanced up to 2 cm from the synovial surface of the knee. Finally, a central screw is placed through the impactor (when static nailing is performed).
2.2. Operati6e choices The indications for static or dynamic nailing remain the same. In 74 fractures, closed intramedullary nailing was performed, whereas in 26, due to difficulties in reduction and in advancing the nail afterwards, a small skin incision was made above the focus of the fracture and, with a very few detachments made with the help of the finger, we facilitated the advancement of the nail into the distal part of the fracture. Blood loss with the closed technique was 350 ml, whereas with the open technique it was 500 ml. The X-irradiation time ranged from 6 to 12 s; the average operative time was 45 min (25 – 70 min).
2.3. Postoperati6e procedures On the first postoperative day, the patient undergoes isometric exercises for the quadriceps and on the second day stands up, without loading or with a partial load, according to the type of the fracture, if his or her general condition permits. Full loading is according to the nailing type: with dynamic nailing we encourage the patient to place full loading from the first week; with static nailing the loading is related to the radiographic imaging of the visible callus. The average duration of hospitalization for isolated fractures was 8 days, whereas for patients with multiple injuries it was 17 days.
3. Results All the patients were assessed clinically and radiologically every month at least until the fractures had healed. Of 97 patients, three died from causes unconnected with the fracture. Of the 97 fractures, 91
309
healed between 8 and 19 weeks (median 12 weeks) (Fig. 2). We consider the fracture healed when the patient walks without pain, without the use of supporting aids, and if the radiographs reveal bridging callus in two projections. Six fractures progressed to non-union, five of which were hypertrophic (one was septic) and one was atrophic in an open fracture of grade II. In four of the six non-unions, open reduction had been used (P= 0.020). Five of six non-unions were managed with exchange nailing and finally healed. One non-union was managed with retention of the existing nail, which finally healed in 15 months. In all six nonunions a nail with five pins had been used (P= 0.026). Three fractures were united with varus deformity of 10°; in one of them there was a coexistent 2-cm shortening. We believe that these complications were due to inappropriate operative technique. In three patients the pins protruded from the anterior cortex. In two of them this protrusion occurred during the operation, at the moment of the advancement of the nail to the area of the femoral trochlea, whereas in the third it happened around the second postoperative month due to severe osteoporosis. There were two cases of deep infection, in one of which healing was normal with the intravenous administration of antibiotics. In the second, the infection led to a septic non-union so we proceeded to the removal of the nail, surgical debridement, placement of external osteosynthesis, and intravenous administration of antibiotics; callus formed in 3 months. A superficial infection occurring in the first postoperative month was treated by surgical debridement and the administration of antibiotics; healing occurred within 8 weeks. There were two cases of pulmonary embolism on the second to third day after injury in patients with multiple injuries, and one case of postoperative embolization in an 82-year-old woman. None of the patients died. Certain intraoperative complications were encountered. In five cases, at the stage of advancement of the nail to the distal fractured part, the protruding wired lock was positioned at an angle and it was impossible to unlock the nail. The nail was removed temporarily, the lock realigned and then repositioned. In three other cases, the lock was withdrawn during the same stage of the operation and the nail unlocked automatically before being advanced. Again, the nail was removed temporarily and was relocked and repositioned. In three more cases, during the same stage, the locking rings of some rods of the nail broke, making it impossible to reposition the nail. In all three, a new nail was used.
310
G. Anastopoulos et al. / Injury, Int. J. Care Injured 32 (2001) 307–312
Fig. 2. (a) Comminuted femoral shaft fracture (AO:C3), preoperative; (b – c) 5-month postoperative F/P radiographs showing that the fracture is consolidated.
G. Anastopoulos et al. / Injury, Int. J. Care Injured 32 (2001) 307–312
311
4. Discussion
References
After our 10-year experience in the treatment of femoral shaft fractures with locking intramedullary nails [16,17], we decided to use the Marcetti – Vicenzi elastic nail due to certain advantages which we considered favourable. Material analysis had revealed that the elastic nail offers stable osteosynthesis, maintaining the reduction performed in relation to rotation, length, and axis, and is sufficient even for comminuted fractures. A contraindication to its use is the presence of severe osteoporosis; in distal-type femoral fractures the intact part should be 8 cm from the joint. It is known that the presence of micromovement and the transfer of loads in the area of a fracture favour callus formation [18]. We believe that the elastic behaviour of the nail is a satisfactory approach to the need for this micromovement and load to transfer, which is why the average time for callus formation was shorter than with the elastic locking nails [19 – 24], both in our series (12 weeks) and in the series of the inventors of the nail [25], with a main characteristic being the formation of abundant periosseous callus. However, the 6% of non-unions in our series is unacceptably high. It seems that Marcetti – Vicenzi nails with five secondary nails do not offer the appropriate stability and that the nail is not adequate for fractures of the distal third of the femur. The outward gradient of 8° in the cylindrical part of the nail permits its introduction just lateral to the tip of the trochanter without fear of a varus deformity in cases of subtrochanteric fractures, resulting in easier access, which is of greater importance in obese patients and especially when a supine position is used. Also, the possibility of aseptic necrosis of the femoral head [26,27] and the induction of neck fracture [28 – 31] is decreased. The limited reaming in the first 12 cm of the femur decreases the duration of the operation, the blood loss and possible intraoperative complications, such as entrapment of the reamer. However, we think that the lack of pin guide for the introduction of the nail is a basic disadvantage because it is certainly easier to introduce a pin guide than the nail, which requires very good reduction of the fracture. In our series, we needed to open the fracture nailing in 26 patients (26%) due to difficulty with introducing the nail. The avoidance of distal locking, which is for many operators the most difficult stage of intramedullary nailing [32,33] and for us the basic advantage of this nail, contributes significantly to the reduction in the amount of X-irradiation and the duration of the operation. In conclusion, we believe that this elastic nail is not to be recommended for the treatment of femoral shaft fractures.
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