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Unreamed femoral nail with spiral blade in subtrochanteric fractures: experience of 55 cases
Injury, Int. J. Care Injured (2004) 35, 191—195
Unreamed femoral nail with spiral blade in subtrochanteric fractures: experience of 55 cases S.P. Datir*, G.S. Bedi, C.H.M. Curwen Department of Orthopaedics, Gloucestershire Royal Hospital, UK Accepted 31 March 2003
KEYWORDS Subtrochanteric fractures; Nailing; Unreamed femoral nailing; Spiral blade; Fracture-fixation; Adult; Retrospective study; Implant failure; Union; Non-union; Fracture classification
Summary Objective: To evaluate the use of the unreamed femoral nail with spiral blade (UFN—SB) in the treatment of subtrochanteric femoral fractures. Design: A retrospective review of a consecutive series of 55 fractures. Fourteen patients had metastatic disease (four had prophylactic nailing). Results: In five fractures, the UFN— SB failed: there was migration in three cases and breakage of the spiral blade in two cases, with breakage of the nail in two cases. Revision surgery was necessary in four cases. Five out of seven complications related to the spiral blade were seen in patients with a Seinsheimer fracture Type IIC or V. All other fractures healed within 1 year including those that needed revision surgery. In two cases the end result was THR. Conclusions: No complication was observed in pathological fractures, which may be because of a high mortality in the first 4 months after surgery due to co morbidity. The main advantage of the nail seems to be its ease of use. It can be inserted through a small incision. The options in spiral blade angle insertion make it a very versatile implant. The implant should probably not be used in Type IIC or V (Seinsheimer) fractures. ß 2003 Published by Elsevier Science Ltd.
Introduction The treatment of subtrochanteric fractures of the femur is unsolved. Internal fixation is the standard treatment and there is a variety of different implants available.15 These implants fall into two main categories, i.e. intramedullary and extramedullary. Extramedullary implants include various types of screw/blade and plate devices. These extramedullary devices have inherent mechanical disadvantages because they are subjected to tension forces. Early weight bearing can lead to implant failure.6 The unreamed femoral nail with spiral blade component (referred to as UFN—SB in this article) *
Corresponding author. Present address: Flat 6, Residence 1, North Staffordshire Hospital, City General, Newcastle Road, Stoke on Trent ST4 6QG, BS16 2 EW, UK. E-mail address: [email protected] (S.P. Datir).
is a relatively new concept introduced in 1994 by the AO group. There are some reports regarding the complications associated with this implant, e.g. breakage and migration of the spiral blade,2—4,18 dislodgement of the locking cap,5 fatigue failure of the spiral blade,19 secondary femoral nail fracture at the nail insertion site.13 We report our experience with this implant in the treatment of traumatic and pathological subtrochanteric femoral fractures.
Patients and methods We reviewed the medical notes and X-rays of 55 consecutive patients (male/female: 18/37) with subtrochanteric fractures treated using the UFN—SB between 1995 and 2001 at Gloucestershire Royal Hospital. Thirty-eight patients had primary
0020–1383/$ — see front matter ß 2003 Published by Elsevier Science Ltd. doi:10.1016/S0020-1383(03)00118-9
192
S.P. Datir et al.
traumatic fractures and 17 had pathological fracture (four were not actually broken at presentation). The mean age was 71 years (range 32—94). Two cases lost to follow up. The mean follow-up was 7 months (range 4—36 months). The main outcome measures included clinical findings in the patient’s medical records (e.g. chronic pain, level of mobility) and radiological findings (union, implant failure). Fractures were classified according to Seinsheimer’s classification.16 Seven different teams of consultants and middle grade surgeons carried out the operations. All fractures were reduced on a standard fracture table before proceeding to surgical fixation with UFN—SB. Distal locking was carried out in all cases but in some cases the proximal locking bolt option was not used. Weight bearing was allowed post-operatively depending upon the patient’s comfort, fracture stability and the individual team’s policy. In three cases an UFN—SB was used for a revision procedure after non-union or previous implant failure (DHS, DCS and Gamma nail failure).
Results Due to the retrospective study design and inadequate medical notes, changes in patient’s mobility and activities of daily living could not be studied.
Pathological fractures Carcinoma of the breast was the commonest primary tumour, followed by non-Hodgkin’s lymphoma
Figure 1
and Carcinoma of the prostate. There was a very high mortality rate and out of 17 patients 8 died within the first 2 months of surgery. This number increased to 12 by 6 months. None of the deaths was directly related to the operative procedure. The average post-operative survival was 4.7 months, which is low compared with other studies.1,9,11,12 No cases of implant failure, fat embolism or deep wound infection were observed in the remaining patients. Pain control was good in all except two patients who were alive after 2 months.
Non-pathological fractures We reviewed 38 non-pathological fractures. Three patients died within 2 months due to unrelated causes and two patients were lost to followup. Thirty-three patients were followed up. In 26 of these cases fractures healed uneventfully. Implant failure was observed in seven patients (21%). Revision surgery was necessary in five patients (13%). The most common fractures seen were Type V and segmental followed by Types IIC and IIIA (Fig. 1). Of the seven implant failures five were related to the spiral blade and two due to the nail breakage at the fracture site. Out of five spiral blade-related complications, four occurred in Seinsheimer Type V fractures and one in Type 2C. Out of five patients in which revision was necessary three were revised with a reamed femoral nail and the other two to THR. In five out of these seven patients the
Implant failure and its relation to fracture type.
Unreamed femoral nail with spiral blade
Figure 2
193
(A) Immediate post-operative X-ray; (B) spiral blade migration after 4 months.
preoperative mobility was unrestricted and the average age was 60 years.
Spiral blade migration This was observed in three patients. In one case the spiral blade migrated into the hip joint and in two cases the spiral blade backed out. In one of these three cases revision to a reamed femoral nail was adequate. In the other two cases removal of the migrated spiral blade was sufficient (Fig. 2).
Spiral blade breakage This was observed in two patients. Both occurred in Type V fractures. In one case the UFN—SB was used as a revision implant after failure of a DHS. Both situations were salvaged by performing a Total Hip Replacement (Fig. 3).
Nail breakage This was observed in two cases and was not directly related to the spiral blade component. Both problems occurred in Type V fractures and cortical
apposition on post-operative X-rays was less than 50%. The average operative time (incision to skin closure) was 60 min (range 45—95 min, n ¼ 40). The average post-operative fall in haemoglobin was 2.6 g% (n ¼ 38).
Discussion Pathological fractures The relatively low average post-operative survival (4.7 months) compared with other studies9,11 may be due to variability of tumour spread. We did not observe any implant failure or other surgical complications. It appears that these patients with multiple metastases have associated co morbid conditions and quite restricted mobility. As a result the implant is subjected to less stress than in healthy patients. Only two patients complained of persistent pain at last follow-up. UFN—SB seems to be effective in the treatment of metastatic subtrochanteric lesions as observed by other authors.1
194
S.P. Datir et al.
There are studies, which suggest that UFN—SB is mechanically weaker compared with other nails.20 The different angle options in spiral blade insertion make it versatile in revision surgery cases, metastatic lesions and where the angle of spiral blade insertion can be changed according to the situation. By avoiding reaming the operative time and blood loss are reduced. This study suggests that the UFN—SB device is good in the treatment of metastatic subtrochanteric lesions but it should probably not be used in Seinsheimer Types V and IIC fractures.
Acknowledgements We are thankful to Radio diagnosis and clinical Audit Department of Gloucestershire Royal Hospital for this study.
References
Figure 3 Spiral blade breakage.
Non-pathological fractures The spiral blade failure rate (21%) and re-intervention rate (13%) observed in this study correlates well with the study of Broos et al. (21 and 9%, respectively). Similar figures in other studies involve the Russell—Taylor nail (less than 10%)8,10,17 and Gamma nail (10—27%)4,7. All complications related to the spiral blade component were observed in Seinsheimer Types V and IIC fractures (Fig. 1). Implant failure and revision rates in Seinsheimer Types V and IIC fractures were 40 and 22%, respectively. It appears that spiral blade failure is mainly related to the intertrochanteric extension of the fracture. The average age of the patients in which these complications occurred was less than the mean age of the whole group. Fracture site motion studies on models with second-generation intramedullary nails suggest that when subtrochanteric fractures are unstable (e.g. comminution, segmental, bone loss) and early weight bearing is desirable, the choice of implant is critical.14 Treatment should be restricted to implants that allow minimal fracture site motion (Long Gamma and Russell—Taylor nails).15
1. Assal M, Zanone X, Peter RE. Osteosynthesis of metastatic femoral lesions of the proximal femur with a solid femoral nail and interlocking spiral blade inserted without reaming. J Orthop Trauma 2000;14:394—7. 2. Broos PLO, Reynders P, Vanderspeeten K. Mechanical complications associated with the use of unreamed AO femoral intramedullary nail with spiral blade: first experience of 35 consecutive cases. J Orthop Trauma 1998;12: 186—9. 3. Broos PLO, Reynders P. The use of the undreamed AO femoral intramedullary nail with spiral blade in nonpathologic fractures of the femur: experience with 80 consecutive cases. J Orthop Trauma 2002;16(3):150—4. 4. Broos PLO, Vanderspeeten K. Our first experience with unreamed femoral nail (UFN). Acta Chir Belg 1997;97: 27—32. 5. Clough TM, Sampath J, Shah V. Dislodgement of the locking cap from the AO unreamed femoral nail: a case report. J Orthop Trauma 2000;14:105—11. 6. Cochran RD. The problem of subtrochanteric fractures of the femur. J Trauma 1971;11:719—20. 7. Docquier PL, Manche E, Autrique JC, Geulette B. Complications associated with gamma nailing. A review of 439 cases. Acta Orthop Belg 2002;68(3):251—7. 8. Garnavos C, Peterman A, Howard PW. The treatment of difficult proximal femoral fractures with the Russell—Taylor reconstruction nail. Injury 1999;30(6):407—15. 9. Harrington KD, Sim FH, Enis JE, et al. Methylmethacrylate as an adjunct in internal fixation of pathological fractures: experience with 375 cases. J Bone Joint Surg (AM) 1976;58: 1047—55. 10. Hoover GK, Browner BD, Cole JD. Initial experience with a second generation locking femoral nail: the Russell—Taylor reconstruction nail. Contemp Orthop 1991;23(3):199—208. 11. Lane JM, Sculco TP, Zolan S. Treatment of pathological fractures of the hip by endoprosthetic replacement. J Bone Joint Surg (AM) 1980;62:954—9. 12. Levy RN, Sherry HS, Siffert RS. Surgical management of metastatic disease of bone at the hip. Clin Orthop 1982;169: 62—9.
Unreamed femoral nail with spiral blade
13. Qureshi F, Gliatis J, Hahn DM. Early failure of spiral blade using with an unreamed femoral nail: a case report. Injury 1999;30:219—20. 14. Roberts CS, Nawab A, Wang M. Second generation intramedullary nailing of subtrochanteric femur fractures: a biomechanical study of fracture site motion. J Orthop Trauma 2002;16(4):231—8. 15. Rockwood CA, Green DP. Rockwood Green’s fracture in adults. 4th ed. New York: Raven; 1666—1681. 16. Seinsheimer F. Subtrochanteric fractures of the femur. J Bone Joint Surg (AM) 1978;60:300.
195
17. Smith JT, Tischenko G. Treatment of comminuted femoral subtrochanteric fractures using the Russell—Taylor reconstruction intramedullary nail. Orthopaedics 1991;14(2):125—9. 18. Sochart DH, Bamford DJ, Paul AS. Failure of the spiral blade module of the AO unreamed femoral nail. Arch Orthop Trauma Surg 1998;117:415—7. 19. Syed AA, Kennedy JG, Mullet H, et al. Fatigue failure of an AO spiral blade. Arch Orthop Trauma Surg 2000;120:366—8. 20. Wheeler DL, Croy TJ, Woll TS, et al. Comparison of reconstruction nails for high subtrochanteric femur fracture fixation. Clin Orthop 1997;338:231—9.
Unreamed femoral nail with spiral blade in subtrochanteric fractures: experience of 55 cases S.P. Datir*, G.S. Bedi, C.H.M. Curwen Department of Orthopaedics, Gloucestershire Royal Hospital, UK Accepted 31 March 2003
KEYWORDS Subtrochanteric fractures; Nailing; Unreamed femoral nailing; Spiral blade; Fracture-fixation; Adult; Retrospective study; Implant failure; Union; Non-union; Fracture classification
Summary Objective: To evaluate the use of the unreamed femoral nail with spiral blade (UFN—SB) in the treatment of subtrochanteric femoral fractures. Design: A retrospective review of a consecutive series of 55 fractures. Fourteen patients had metastatic disease (four had prophylactic nailing). Results: In five fractures, the UFN— SB failed: there was migration in three cases and breakage of the spiral blade in two cases, with breakage of the nail in two cases. Revision surgery was necessary in four cases. Five out of seven complications related to the spiral blade were seen in patients with a Seinsheimer fracture Type IIC or V. All other fractures healed within 1 year including those that needed revision surgery. In two cases the end result was THR. Conclusions: No complication was observed in pathological fractures, which may be because of a high mortality in the first 4 months after surgery due to co morbidity. The main advantage of the nail seems to be its ease of use. It can be inserted through a small incision. The options in spiral blade angle insertion make it a very versatile implant. The implant should probably not be used in Type IIC or V (Seinsheimer) fractures. ß 2003 Published by Elsevier Science Ltd.
Introduction The treatment of subtrochanteric fractures of the femur is unsolved. Internal fixation is the standard treatment and there is a variety of different implants available.15 These implants fall into two main categories, i.e. intramedullary and extramedullary. Extramedullary implants include various types of screw/blade and plate devices. These extramedullary devices have inherent mechanical disadvantages because they are subjected to tension forces. Early weight bearing can lead to implant failure.6 The unreamed femoral nail with spiral blade component (referred to as UFN—SB in this article) *
Corresponding author. Present address: Flat 6, Residence 1, North Staffordshire Hospital, City General, Newcastle Road, Stoke on Trent ST4 6QG, BS16 2 EW, UK. E-mail address: [email protected] (S.P. Datir).
is a relatively new concept introduced in 1994 by the AO group. There are some reports regarding the complications associated with this implant, e.g. breakage and migration of the spiral blade,2—4,18 dislodgement of the locking cap,5 fatigue failure of the spiral blade,19 secondary femoral nail fracture at the nail insertion site.13 We report our experience with this implant in the treatment of traumatic and pathological subtrochanteric femoral fractures.
Patients and methods We reviewed the medical notes and X-rays of 55 consecutive patients (male/female: 18/37) with subtrochanteric fractures treated using the UFN—SB between 1995 and 2001 at Gloucestershire Royal Hospital. Thirty-eight patients had primary
0020–1383/$ — see front matter ß 2003 Published by Elsevier Science Ltd. doi:10.1016/S0020-1383(03)00118-9
192
S.P. Datir et al.
traumatic fractures and 17 had pathological fracture (four were not actually broken at presentation). The mean age was 71 years (range 32—94). Two cases lost to follow up. The mean follow-up was 7 months (range 4—36 months). The main outcome measures included clinical findings in the patient’s medical records (e.g. chronic pain, level of mobility) and radiological findings (union, implant failure). Fractures were classified according to Seinsheimer’s classification.16 Seven different teams of consultants and middle grade surgeons carried out the operations. All fractures were reduced on a standard fracture table before proceeding to surgical fixation with UFN—SB. Distal locking was carried out in all cases but in some cases the proximal locking bolt option was not used. Weight bearing was allowed post-operatively depending upon the patient’s comfort, fracture stability and the individual team’s policy. In three cases an UFN—SB was used for a revision procedure after non-union or previous implant failure (DHS, DCS and Gamma nail failure).
Results Due to the retrospective study design and inadequate medical notes, changes in patient’s mobility and activities of daily living could not be studied.
Pathological fractures Carcinoma of the breast was the commonest primary tumour, followed by non-Hodgkin’s lymphoma
Figure 1
and Carcinoma of the prostate. There was a very high mortality rate and out of 17 patients 8 died within the first 2 months of surgery. This number increased to 12 by 6 months. None of the deaths was directly related to the operative procedure. The average post-operative survival was 4.7 months, which is low compared with other studies.1,9,11,12 No cases of implant failure, fat embolism or deep wound infection were observed in the remaining patients. Pain control was good in all except two patients who were alive after 2 months.
Non-pathological fractures We reviewed 38 non-pathological fractures. Three patients died within 2 months due to unrelated causes and two patients were lost to followup. Thirty-three patients were followed up. In 26 of these cases fractures healed uneventfully. Implant failure was observed in seven patients (21%). Revision surgery was necessary in five patients (13%). The most common fractures seen were Type V and segmental followed by Types IIC and IIIA (Fig. 1). Of the seven implant failures five were related to the spiral blade and two due to the nail breakage at the fracture site. Out of five spiral blade-related complications, four occurred in Seinsheimer Type V fractures and one in Type 2C. Out of five patients in which revision was necessary three were revised with a reamed femoral nail and the other two to THR. In five out of these seven patients the
Implant failure and its relation to fracture type.
Unreamed femoral nail with spiral blade
Figure 2
193
(A) Immediate post-operative X-ray; (B) spiral blade migration after 4 months.
preoperative mobility was unrestricted and the average age was 60 years.
Spiral blade migration This was observed in three patients. In one case the spiral blade migrated into the hip joint and in two cases the spiral blade backed out. In one of these three cases revision to a reamed femoral nail was adequate. In the other two cases removal of the migrated spiral blade was sufficient (Fig. 2).
Spiral blade breakage This was observed in two patients. Both occurred in Type V fractures. In one case the UFN—SB was used as a revision implant after failure of a DHS. Both situations were salvaged by performing a Total Hip Replacement (Fig. 3).
Nail breakage This was observed in two cases and was not directly related to the spiral blade component. Both problems occurred in Type V fractures and cortical
apposition on post-operative X-rays was less than 50%. The average operative time (incision to skin closure) was 60 min (range 45—95 min, n ¼ 40). The average post-operative fall in haemoglobin was 2.6 g% (n ¼ 38).
Discussion Pathological fractures The relatively low average post-operative survival (4.7 months) compared with other studies9,11 may be due to variability of tumour spread. We did not observe any implant failure or other surgical complications. It appears that these patients with multiple metastases have associated co morbid conditions and quite restricted mobility. As a result the implant is subjected to less stress than in healthy patients. Only two patients complained of persistent pain at last follow-up. UFN—SB seems to be effective in the treatment of metastatic subtrochanteric lesions as observed by other authors.1
194
S.P. Datir et al.
There are studies, which suggest that UFN—SB is mechanically weaker compared with other nails.20 The different angle options in spiral blade insertion make it versatile in revision surgery cases, metastatic lesions and where the angle of spiral blade insertion can be changed according to the situation. By avoiding reaming the operative time and blood loss are reduced. This study suggests that the UFN—SB device is good in the treatment of metastatic subtrochanteric lesions but it should probably not be used in Seinsheimer Types V and IIC fractures.
Acknowledgements We are thankful to Radio diagnosis and clinical Audit Department of Gloucestershire Royal Hospital for this study.
References
Figure 3 Spiral blade breakage.
Non-pathological fractures The spiral blade failure rate (21%) and re-intervention rate (13%) observed in this study correlates well with the study of Broos et al. (21 and 9%, respectively). Similar figures in other studies involve the Russell—Taylor nail (less than 10%)8,10,17 and Gamma nail (10—27%)4,7. All complications related to the spiral blade component were observed in Seinsheimer Types V and IIC fractures (Fig. 1). Implant failure and revision rates in Seinsheimer Types V and IIC fractures were 40 and 22%, respectively. It appears that spiral blade failure is mainly related to the intertrochanteric extension of the fracture. The average age of the patients in which these complications occurred was less than the mean age of the whole group. Fracture site motion studies on models with second-generation intramedullary nails suggest that when subtrochanteric fractures are unstable (e.g. comminution, segmental, bone loss) and early weight bearing is desirable, the choice of implant is critical.14 Treatment should be restricted to implants that allow minimal fracture site motion (Long Gamma and Russell—Taylor nails).15
1. Assal M, Zanone X, Peter RE. Osteosynthesis of metastatic femoral lesions of the proximal femur with a solid femoral nail and interlocking spiral blade inserted without reaming. J Orthop Trauma 2000;14:394—7. 2. Broos PLO, Reynders P, Vanderspeeten K. Mechanical complications associated with the use of unreamed AO femoral intramedullary nail with spiral blade: first experience of 35 consecutive cases. J Orthop Trauma 1998;12: 186—9. 3. Broos PLO, Reynders P. The use of the undreamed AO femoral intramedullary nail with spiral blade in nonpathologic fractures of the femur: experience with 80 consecutive cases. J Orthop Trauma 2002;16(3):150—4. 4. Broos PLO, Vanderspeeten K. Our first experience with unreamed femoral nail (UFN). Acta Chir Belg 1997;97: 27—32. 5. Clough TM, Sampath J, Shah V. Dislodgement of the locking cap from the AO unreamed femoral nail: a case report. J Orthop Trauma 2000;14:105—11. 6. Cochran RD. The problem of subtrochanteric fractures of the femur. J Trauma 1971;11:719—20. 7. Docquier PL, Manche E, Autrique JC, Geulette B. Complications associated with gamma nailing. A review of 439 cases. Acta Orthop Belg 2002;68(3):251—7. 8. Garnavos C, Peterman A, Howard PW. The treatment of difficult proximal femoral fractures with the Russell—Taylor reconstruction nail. Injury 1999;30(6):407—15. 9. Harrington KD, Sim FH, Enis JE, et al. Methylmethacrylate as an adjunct in internal fixation of pathological fractures: experience with 375 cases. J Bone Joint Surg (AM) 1976;58: 1047—55. 10. Hoover GK, Browner BD, Cole JD. Initial experience with a second generation locking femoral nail: the Russell—Taylor reconstruction nail. Contemp Orthop 1991;23(3):199—208. 11. Lane JM, Sculco TP, Zolan S. Treatment of pathological fractures of the hip by endoprosthetic replacement. J Bone Joint Surg (AM) 1980;62:954—9. 12. Levy RN, Sherry HS, Siffert RS. Surgical management of metastatic disease of bone at the hip. Clin Orthop 1982;169: 62—9.
Unreamed femoral nail with spiral blade
13. Qureshi F, Gliatis J, Hahn DM. Early failure of spiral blade using with an unreamed femoral nail: a case report. Injury 1999;30:219—20. 14. Roberts CS, Nawab A, Wang M. Second generation intramedullary nailing of subtrochanteric femur fractures: a biomechanical study of fracture site motion. J Orthop Trauma 2002;16(4):231—8. 15. Rockwood CA, Green DP. Rockwood Green’s fracture in adults. 4th ed. New York: Raven; 1666—1681. 16. Seinsheimer F. Subtrochanteric fractures of the femur. J Bone Joint Surg (AM) 1978;60:300.
195
17. Smith JT, Tischenko G. Treatment of comminuted femoral subtrochanteric fractures using the Russell—Taylor reconstruction intramedullary nail. Orthopaedics 1991;14(2):125—9. 18. Sochart DH, Bamford DJ, Paul AS. Failure of the spiral blade module of the AO unreamed femoral nail. Arch Orthop Trauma Surg 1998;117:415—7. 19. Syed AA, Kennedy JG, Mullet H, et al. Fatigue failure of an AO spiral blade. Arch Orthop Trauma Surg 2000;120:366—8. 20. Wheeler DL, Croy TJ, Woll TS, et al. Comparison of reconstruction nails for high subtrochanteric femur fracture fixation. Clin Orthop 1997;338:231—9.