Hip Pelvis.  2017 Jun;29(2):113-119. 10.5371/hp.2017.29.2.113.

Clinical Results of Complex Subtrochanteric Femoral Fractures with Long Cephalomedullary Hip Nail

• Kim KK
• Won Y
• Smith DH
• Lee GS
• Lee HY

• KMID: 2424239
• DOI: http://doi.org/10.5371/hp.2017.29.2.113

Abstract

PURPOSE
Good results of the cephalomedullary nails have been reported in proximal femoral fractures recently. Based on length of nails and shape of screws fixed in a femoral head for proximal fragment fixation, the proper nail length was in dispute. The purpose of this study was to evaluate the clinical and radiological results of a long cephalomedullary hip nail for the treatment of comminuted subtrochanteric femoral fractures.
MATERIALS AND METHODS
Twenty-one consecutive patients with severe subtrochanteric femoral fractures who had undergone intramedullary fixation using long-PFNA II between March 2010 and March 2013 were followed-up for over 12 months. Their mean age was 64.8 years old (range, 43-85 years). Sixteen of 22 cases were high energy trauma. According to Seinsheimer's classification, 5 cases were type IV and 16 cases were type V. For radiological assessment, time to union, change of neck-shaft angle, sliding length, tip-apex distance (TAD) and leg length discrepancy (LLD) were measured. For clinical evaluation, a modified Koval index was investigated.
RESULTS
Mean operation time was 96 minutes. An average decrease of neck-shaft angle was 4.5°. The average sliding length of the helical blade was 4.2 mm. Average LLD was 3.0 mm, and TAD was 23.0 mm. Mean modified Koval index score at final follow-up was 4.6 points. All the 21 subtrochanteric fractures healed uneventfully on an average of 24.2 weeks (range, 18-30 weeks).
CONCLUSION
Long cephalomedullary hip nail provides excellent clinical and radiological outcomes in the comminuted subtrochanteric fracture.

Keyword

Femur; Subtrochanteric fracture; Long cephalomedullary hip nail

MeSH Terms

Classification
Dissent and Disputes
Femoral Fractures*
Femur
Follow-Up Studies
Head
Hip Fractures
Hip*
Humans
Leg

Figure

• 

  Fig. 1 Plain radiographs of comminuted subtrochanteric fracture of a 53-year-old male patient. (A) Preoperative radiograph. (B) Immediate postoperative radiograph. (C) Post-operative 8 months follow-up radiograph.

• 

  Fig. 2 Seventy three year old male patient complained lateral aspect pain at the left lateral position. (A) Immediate postoperative radiographs. (B) One year after operation radiograph that shows sliding of helical blade screw. (C) Helical blade screw was removed due to sustained discomforts and pain on the trochanteric region.

Reference

1. Min BW, Song KS, Bae KC, Cho CH, Son ES, Lee KJ. Nonsurgical treatment strategies after osteoporotic hip fractures. Hip Pelvis. 2015; 27:9–16.

2. Bedi A, Toan Le T. Subtrochanteric femur fractures. Orthop Clin North Am. 2004; 35:473–483.

3. Fielding JW, Cochran GV, Zickel RE. Biomechanical characteristics and surgical management of subtrochanteric fractures. Orthop Clin North Am. 1974; 5:629–650.

4. Froimson AI. Treatment of comminuted subtrochanteric fractures of the femur. Surg Gynecol Obstet. 1970; 131:465–472.

5. Saini P, Kumar R, Shekhawat V, Joshi N, Bansal M, Kumar S. Biological fixation of comminuted subtrochanteric fractures with proximal femur locking compression plate. Injury. 2013; 44:226–231.

6. Kim JW, Chang JS, Lee H, Bae JY, Kim JJ. Clinical results of femoral subtrochanteric fractures. J Korean Hip Soc. 2010; 22:222–226.

7. Hotz TK, Zellweger R, Kach KP. Minimal invasive treatment of proximal femur fractures with the long gamma nail: indication, technique, results. J Trauma. 1999; 47:942–945.

8. Ruff ME, Lubbers LM. Treatment of subtrochanteric fractures with a sliding screw-plate device. J Trauma. 1986; 26:75–80.

9. Lee JY, Lee SY. Treatment of the proximal femoral extracapsular fracture with proximal femoral nail antirotation (PFNA): Comparison with proximal femoral nail (PFN). J Korean Hip Soc. 2007; 19:183–189.

10. Borens O, Wettstein M, Kombot C, Chevalley F, Mouhsine E, Garofalo R. Long gamma nail in the treatment of subtrochanteric fractures. Arch Orthop Trauma Surg. 2004; 124:443–447.

11. Windolf M, Braunstein V, Dutoit C, Schwieger K. Is a helical shaped implant a superior alternative to the Dynamic Hip Screw for unstable femoral neck fractures? A biomechanical investigation. Clin Biomech (Bristol, Avon). 2009; 24:59–64.

12. Strauss E, Frank J, Lee J, Kummer FJ, Tejwani N. Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures: a biomechanical evaluation. Injury. 2006; 37:984–989.

13. Ahrengart L, Törnkvist H, Fornander P, et al. A randomized study of the compression hip screw and Gamma nail in 426 fractures. Clin Orthop Relat Res. 2002; (401):209–222.

14. Chung PH, Kang S, Kim JP, Kim YS, Lee HM, Huh DJ. Treatment of unstable pertrochanteric fractures with a long intramedullary nail. Hip Pelvis. 2013; 25:51–56.

15. Menezes DF, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop Relat Res. 2005; 439:221–227.

16. Ongkiehonga BD, Leemansb R. Proximal femoral nail failure in a subtrochanteric fracture: the importance of fracture to distal locking screw distance. Injry Extra. 2007; 38:445–450.

17. Rockwood CA, Green DP, Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P. Rockwood and Green's fractures in adults. 7th ed. Philadelphia: Lippincott Williams & Wilkins;2010.

18. Park J, Yang KH. Correction of malalignment in proximal femoral nailing--Reduction technique of displaced proximal fragment. Injury. 2010; 41:634–638.

19. Yang KH, Won Y, Kang DH, Oh JC, Kim SJ. Role of appositional screw fixation in minimally invasive plate osteosynthesis for distal tibial fracture. J Orthop Trauma. 2015; 29:e331–e335.

20. Ogata K, Goldsand EM. A simple biplanar method of measuring femoral anteversion and neck-shaft angle. J Bone Joint Surg Am. 1979; 61:846–851.

21. Bendo JA, Weiner LS, Strauss E, Yang E. Collapse of intertrochanteric hip fractures fixed with sliding screws. Orthop Rev. 1994; Suppl:30–37.

22. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995; 77:1058–1064.

23. Koval KJ, Skovron ML, Aharonoff GB, Meadows SE, Zuckerman JD. Ambulatory ability after hip fracture. A prospective study in geriatric patients. Clin Orthop Relat Res. 1995; (310):150–159.

24. Jiang LS, Shen L, Dai LY. Intramedullary fixation of subtrochanteric fractures with long proximal femoral nail or long gamma nail: technical notes and preliminary results. Ann Acad Med Singapore. 2007; 36:821–826.

25. Windolf J, Hollander DA, Hakimi M, Linhart W. Pitfalls and complications in the use of the proximal femoral nail. Langenbecks Arch Surg. 2005; 390:59–65.

26. Tencer AF, Johnson KD, Johnston DW, Gill K. A biomechanical comparison of various methods of stabilization of subtrochanteric fractures of the femur. J Orthop Res. 1984; 2:297–305.

27. Won Y, Yang KH, Kim KK, Weaver MJ, Allen EM. Amputated limb by cerclage wire of femoral diaphyseal fracture: a case report. Arch Orthop Trauma Surg. 2016; 136:1691–1694.

28. Okcu G, Ozkayin N, Okta C, Topcu I, Aktuglu K. Which implant is better for treating reverse obliquity fractures of the proximal femur: a standard or long nail? Clin Orthop Relat Res. 2013; 471:2768–2775.

29. Lindvall E, Ghaffar S, Martirosian A, Husak L. Short versus long intramedullary nails in the treatment of pertrochanteric hip fractures: incidence of ipsilateral fractures and costs associated with each implant. J Orthop Trauma. 2016; 30:119–124.

30. Wang WY, Yang TF, Fang Y, Lei MM, Wang GL, Liu L. Treatment of subtrochanteric femoral fracture with long proximal femoral nail antirotation. Chin J Traumatol. 2010; 13:37–41.

31. Im GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. J Orthop Trauma. 2005; 19:5–9.

32. McConnell T, Tornetta P 3rd, Benson E, Manuel J. Gluteus medius tendon injury during reaming for gamma nail insertion. Clin Orthop Relat Res. 2003; (407):199–202.