Injury, Int. J. Care Injured 46 (2015) 729–733
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Salvage for nail breakage in femoral intramedullary nailing Marcos Cruz-Sa´nchez *, Rau´l Torres-Claramunt, Albert Alier-Fabrego´, Santos Martı´nez-Dı´az Orthopaedic Department, Parc de Salut Mar. Barcelona, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 4 December 2014
Proximal fractures of femur represent an important cause of hospitalization, morbidity and mortality for elderly patients. Femoral intramedullary nailing is an option to achieve a stable osteosynthesis but the breakage is a rare complication. The aim was to determinate the prevalence, causes, management and functional outcomes of this patients in our hands. Retrospective review of 1246 proximal femur fractures operated between 2003 and 2012. We analyse epidemiological data, fracture type and the quality of closed reduction and fixation by preoperative and postoperative radiology. Type of salvage procedure chosen for each case is presented. Functional outcome and quality of life questionnaire was obtained by Barthel index and Short Form 12 version 2. 11 cases (0.88%) were identified. The type of initial fracture was 7 cases AO/OTA 31A3 and 4 cases AO/ OTA 31A2. The implant failure was detected at 11 months after surgery (SD 6.39). Nail breakage occurred in three different points: 7 cases in the proximal aperture, 3 cases in cervicocephalic screw and 1 case in the distal aperture of the nail. The association of nonunion at fracture site and progressive hip pain was observed in all cases. Different salvage procedures were performed: 7 cases osteosynthesis revision (nail or dynamic condilar screw plate), 2 cases arthroplasty and 2 cases conservative treatment. The main Barthel score before the salvage procedure was 63.2 (SD 13). At final follow-up, this score improved to 72.8 (SD 20.38). To the best of our knowledge, this study represents the largest series of cases of trochanteric nail breakage due to material fatigue. This complication is rare (0.88%) that can foresee in unstable fractures with delayed union. The type of salvage should be individualized showing acceptable functional outcome in our series. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Pertrochanteric fracture Nail breakage Nonunion Salvage procedure Functional outcome
Introduction Proximal fractures of the femur represent an important cause of hospitalization, morbidity and mortality for elderly patients in industrialized countries [1]. Those fractures affecting the neck or head of the femur (AO/OTA 31B or C) are normally treated with an arthroplasty or osteosynthesis with cannulated screws. Otherwise, extra-articular fractures (AO/OTA 31A) are more commonly treated with osteosynthesis, mostly an intramedullary nail or a dynamic hip screw (DHS, Synthes, Solothurn, Switzerland). While both systems are recommended for stable fractures (AO/OTA 31A1), the intramedullary device is preferable for unstable fractures (AO/OTA 31A2–31A3) [2].
* Corresponding author at: Passeig Maritim 25-29, 08003 Barcelona, Spain. Tel.: +34 932480000; fax: +34 932483254. E-mail address: [email protected] (M. Cruz-Sa´nchez). http://dx.doi.org/10.1016/j.injury.2014.12.003 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
The biomechanical advantage of the nail with regard to the DHS is related to its position which is nearer to the weight-bearing axis. When the intramedullary system is compared with the extramedullary device, there is up to a 30% reduction of bending stresses [3]. A decrease in the blood loss and the periostium preservation are other advantages related to the minimal approach needed to place an intramedullary nail [4]. For these reasons, the number of these fractures treated with an intramedullary nail has been increased in the last decade, even for stable fractures [5]. Breakage of the intramedullary nail is an uncommon complication. The causes of this breakage are related to variables depending on the patient (osteoporosis, and associated morbidity) and others depending on the surgery (incorrect implant positioning or poor fracture reduction) [6]. The implant failure usually occurs when the fracture does not achieve the consolidation. Management of this complication includes conversion to total hip arthroplasty (THA) [7,8] or osteosynthesis revision [9]. Different authors have observed that most of these failures occur at the
M. Cruz-Sa´nchez et al. / Injury, Int. J. Care Injured 46 (2015) 729–733
730
intramedullary nail hole performed to cross the cervical screw [6,9]. However, the low number of patients included in these series make difficult to obtain conclusions and get a consensus related to the best practices in the management of this complication. The purpose of this study was to determine the prevalence, possible causes and management of this complication as well as the final functional outcomes of these patients in our hands. For this reason it was contemplated a large series of cases operated during 10 years in a single centre. Material and methods Retrospective study includes all patients operated for proximal femoral fractures with an intramedullary nail from January 2003 to December 2012 in a single department. A total of 1246 fractures were assessed, 573 men and 673 women, with a mean age of 82.3 years (range 51–101). Mean follow-up of these 1246 patients was 13 months (range 3–108). In most cases (1117) a Gamma 31 system (Stryker Trauma, Germany) was used. The other implants used were: 52 Affixus1 (DePuy Orthopedics, USA), 14 LNS-GT1 (Surgival, Spain) and 63 PFNA1 (Synthes, Solothurn, Switzerland). In all cases an antibiotic prophylaxis was performed and in most cases spinal anaesthesia was used. The surgical technique used in all cases was similar: the patient was placed in a traction table (Maquet1) to obtain a reduction of the fracture under fluoroscopic control. All nails were implanted by a 5 cm wound incision proximal to the trochanter. The decision of using a cervical-diaphyseal angle of 1258 or 1308 depended on the surgeon criteria. In all cases distal locking with 1 or 2.5-mm screw was done. Eleven cases out of 1246 presented an implant rupture (0.88%) at final follow-up. The initial fractures of these 11 cases were classified following the AO/OTA classification. Osteoporosis was also assessed following the Singh classification [10]. In Table 1 the epidemiological data of these patients, type of fracture, nail used in each case, time until the implant rupture, location where the nail failed and treatment is shown. In these 11 patients the mean follow-up was 36 months (range 12–96). A radiological study of these 11 patients was assessed after the first procedure using the Picture Archiving and Communication System (Centricity PACS-IW GE Healthcare1). For this, the suggestions of Lobo-Escolar et al. were followed for these types of osteosynthesis [11]. On the anteroposterior view different parameters were evaluated; the distance from the tip of the lag screw to femoral apex (in mm), Parker’s ratio [12], cervical-diaphyseal angle and fracture diastasis (in mm). On the lateral view, the position of the lag screw was assessed considering that this position was posterior if the ratio was 0.66 [12,13]. Different surgical salvage procedures were used in these 11 cases depending on the type of previous fracture, quality of the remaining bone as well as the surgeon criteria. In these patients the
Barthel score in the preoperative and postoperative period of the salvage surgery was also assessed as well as the SF-12 score at the final follow-up. Statistics Statistical analysis was performed by using the SPSS version 15.0 (SPSS Inc., Chicago, IL) statistical package. Continuous variables are presented as mean and standard deviation or range and categorical variables as percentages. A bivariant analysis of all radiological or clinical factors potentially associated with nail breakage was performed. Pearson’s correlation test was used for categorical variables. Throughout the statistics analysis the p value set at 3 mm) might be related to a
Fig. 1. The three different types of implant breakage.
Fig. 2. Treatment of the cervicocephalic screw breakage.
732
M. Cruz-Sa´nchez et al. / Injury, Int. J. Care Injured 46 (2015) 729–733
Fig. 3. Case treated with long nail due to a proximal aperture nail breakage.
lack of healing of the fracture overloading the nail and leading to its breakage. The reported prevalence of this complication ranged from 0.2 to 5.7% [6,14–16]. As far as we know, A´lvarez et al. [6] reviewed the largest series of implant breakage following this procedure. In this series, they found 5 cases of implant breakage in 843 cases operated during 12 years in a single centre. In the series that we present here, this complication has been identified in the 0.88% of cases in a large series including 1246 patients operated in a single centre. All fractures that presented this complication were initially classified as unstable fractures. All of them were presented as nonunion at the fracture site at the last follow-up previous to the implant breakage. The cause may be related to the fact that any nail can resist a specific number of cycles and the lack of healing at a
certain time might cause an implant failure [6,17,18]. In accordance with other series [15,17,19] the implant breakage takes place from 3 months to 2 years after the surgery. In our series this moment occurred at 11 months after the surgery. It is known that not achieving an optimal fracture reduction could lead to nonunion of the fracture [11]. In all cases, the distance between both fragments exceeds 3 mm, although, in most of cases, the position of the nail was acceptable in both antero-posterior and axial radiological view. It could be recommended that, in those patients with persistent pain at 6 months of follow-up with a suboptimal reduction and lack of consolidation signs, to consider dynamisation of the intramedullary device to avoid the implant breakage. In the largest published series [6,17], most of implant failure occurred in the proximal aperture of the nail. This point could be
Fig. 4. Method used for removal of the implant.
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on the patient status, the remaining bone stock in the femoral head and the surgeon preferences.
Conflict of interest Authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.
References
Fig. 5. Case at 1 year postoperative of proximal nail aperture treated with 958-DCS.
considered as the weakest point of the nail where forces come from the pelvis and are transmitted to the lower part of the nail. In fact, an incorrect placing of the cervical screw may cause erosion of the nail in this position [20]. In the series presented, this complication has been observed in other 2 points of the implant: 3 cases in the cephalic screw and 1 case at the distal aperture of the nail [6,21,22] (Fig. 2). Distinctively to other series described in literature, 3 cases of breakage at the cephalic screw were observed. These ruptures were observed at the beginning of the screw threads. It could be thought that this is the weakest point of the screw. The therapeutic decision-making was mostly influenced by the remaining bone stock at the femoral head and the location of the initial fracture. It was considered that those patients who suffered a cephalic screw rupture had to be treated only with salvage procedure, an arthroplasty. In our series the remaining type of implant breakages were treated with a new osteosynthesis (DCS Synthes, Solothurn, Switzerland vs long nail Gamma3, Stryker Trauma, Germany) due to an acceptable bone stock at the femoral head. In the literature [17] most of cases with similar implant breakage were treated using an arthroplasty. It might be that it is difficult to remove the broken nail. For this, different methods and surgical procedures have been described in the literature in order to facilitate the implant removal [23,24] (Fig. 4). Functional scores and quality of life scores recorded in these 11 patients showed that these patients maintain an acceptable functionality and quality of life at the final follow-up. Patients who had suffered a proximal femoral fracture at same socio demographic background shown a similar result at 1 year follow up (Barthel: 72,63, SF-36: MCS 40.8, PCS 40.24) [25]. Although this are the longest case-series with this complication, the fact of having 11 patients make it difficult to take conclusions about the functionality of these patients after these procedures. In addition, it was difficult to consider all patients as a homogeneous group because the status of each patient previous to the initial fracture was quite different. Nevertheless, as far as we know, this is the first study including functional and quality of life test for patients who suffered this complication. Regarding to the limitations, this is a retrospective study due to the low frequency of this complication and all the conclusions should be interpreted with caution. In conclusion, the prevalence of this complication in this large series is 0.88%. Different treatments may be considered depending
[1] Keene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip fractures. BMJ 1993;307:1248–50. [2] Schipper IB, Steyerberg EW, Castelein RM, van der Heijden FHWM, den Hoed PT, Kerver AJH, et al. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. J Bone Joint Surg Br 2004;86–94. [3] Leung KS, Chen CM, So WS, Sato K, Lai CH, Machaisavariya B, et al. Multicenter trial of modified Gamma nail in East Asia. Clin Orthop Relat Res 1996;146–54. [4] Bojan AJ, Beimel C, Speitling A, Taglang G, Ekholm C, Jo¨nsson A. 3066 consecutive Gamma Nails. 12 years experience at a single centre. BMC Musculoskelet Disord 2010;11:133. [5] Palm H, Lyse´n C, Krasheninnikoff M, Holck K, Jacobsen S, Gebuhr P. Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter: 311 consecutive patients followed for 1 year. Acta Orthop 2011;82:166–70. [6] Bertrand A´lvarez D, Paz Aparicio J, Lopez-Anglada Fernandez E, Gonzalez˜ ez Batalla D, Paz Jime´nez J. Implant breakage, a rare Busto Mugica I, Nu´n complication with the Gamma nail: a review of 843 fractures of the proximal femur treated with a Gamma nail. Acta Orthop Belg 2004;435–43. [7] Winemaker M, Gamble P, Petruccelli D, Kaspar S, de Beer J. Short-term outcomes of total hip arthroplasty after complications of open reduction internal fixation for hip fracture. J Arthroplasty 2006;21:682–8. [8] Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. J Bone Joint Surg Am 2003;85-A:899–904. [9] Kasimatis GB, Lambiris E, Tyllianakis M, Giannikas D, Mouzakis D, Panagiotopoulos E. Gamma nail breakage: a report of four cases. J Orthop Surg (Hong Kong) 2007;368–72. [10] Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am 1970;52:457–67. [11] Lobo-Escolar A, Joven E, Iglesias D, Herrera A. Predictive factors for cutting-out in femoral intramedullary nailing. Injury 2010;41:1312–6. [12] Parker MJ. Cutting-out of the dynamic hip screw related to its position. J Bone Joint Surg 1992;74-B:625. [13] Parmar V, Kumar S, Aster A, Harper WH. Review of methods to quantify lag screw placement in hip fracture fixation. Acta Orthop Belg 2005;260–3. [14] Docquier PL, Manche E, Autrique JC, Geulette B. Complications associated with Gamma nailing a review of 439 cases. Acta Orthop Belg 2002;68:251–7. [15] Boriani S, De Iure F, Bettelli G, Specchia L, Bungaro P, Montari G, et al. The results of a multicenter Italian study on the use of the Gamma nail for the treatment of pertrochanteric and subtrochanteric fractures: a review of 1181 cases. La Chir Org di Mov 1994;79(2):193–203. [16] Pervez H, Parker MJ. Results of the long Gamma nail for complex proximal femoral fractures. Injury 2001;32:704–7. [17] Wee JLH, Sathappan SS, Yeo MSW, Low YP. Management of gamma nail breakage with bipolar hemi-arthroplasty. Singapore Med J 2009;50. [18] Zafiropoulos G, Pratt DJ. Fractured Gamma nail. Injury 1994;25:331–6. [19] Maes M, Deboer Y, Brabants K. Failure of the titanium trochanteric Gamma nail in ununited metastatic fractures. Acta Orthop Belg 2012;78:552–7. [20] Seral B, Albareda J, Lasierra JM, Seral F. Estudio clı´nico de la osteosı´ntesis intra y extramedular en las fracturas trocante´reas de cadera. Rev Ortop Traumatol 2001;5:374–83. [21] Gabler H, Salem G, Strahberger E. The treatment of pertrochanteric fractures of the femur. A report on 642 cases. Bruns Beitr Klin Chir 1966;213:257–75. [22] Valverde JA, Alonso MG, Porro JG, Rueda D, Larrauri PM, Soler JJ. Use of the Gamma nail in the treatment of fractures of the proximal femur. Clin Orthop Relat Res 1998;56–61. [23] Acharya M, Alani A, Almedghio S. The fish hook technique of extracting broken intramedullary nails. Acta Orthop Belg 2008;74:686–8. [24] Angelini M, McKee MD, Waddell JP, Haidukewych G, Schemitsch EH. Salvage of failed hip fracture fixation. J Orthop Trauma 2009;23:471–8. [25] Pidemunt-Moli G. Factores determinantes en el deterioro de la funcio´n y calidad de vida del anciano afecto de fractura de cadera [Doctoral thesis]. Autonomous University of Barcelona; 2009, Retrieved from http://www.tdx. cat.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Salvage for nail breakage in femoral intramedullary nailing Marcos Cruz-Sa´nchez *, Rau´l Torres-Claramunt, Albert Alier-Fabrego´, Santos Martı´nez-Dı´az Orthopaedic Department, Parc de Salut Mar. Barcelona, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 4 December 2014
Proximal fractures of femur represent an important cause of hospitalization, morbidity and mortality for elderly patients. Femoral intramedullary nailing is an option to achieve a stable osteosynthesis but the breakage is a rare complication. The aim was to determinate the prevalence, causes, management and functional outcomes of this patients in our hands. Retrospective review of 1246 proximal femur fractures operated between 2003 and 2012. We analyse epidemiological data, fracture type and the quality of closed reduction and fixation by preoperative and postoperative radiology. Type of salvage procedure chosen for each case is presented. Functional outcome and quality of life questionnaire was obtained by Barthel index and Short Form 12 version 2. 11 cases (0.88%) were identified. The type of initial fracture was 7 cases AO/OTA 31A3 and 4 cases AO/ OTA 31A2. The implant failure was detected at 11 months after surgery (SD 6.39). Nail breakage occurred in three different points: 7 cases in the proximal aperture, 3 cases in cervicocephalic screw and 1 case in the distal aperture of the nail. The association of nonunion at fracture site and progressive hip pain was observed in all cases. Different salvage procedures were performed: 7 cases osteosynthesis revision (nail or dynamic condilar screw plate), 2 cases arthroplasty and 2 cases conservative treatment. The main Barthel score before the salvage procedure was 63.2 (SD 13). At final follow-up, this score improved to 72.8 (SD 20.38). To the best of our knowledge, this study represents the largest series of cases of trochanteric nail breakage due to material fatigue. This complication is rare (0.88%) that can foresee in unstable fractures with delayed union. The type of salvage should be individualized showing acceptable functional outcome in our series. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Pertrochanteric fracture Nail breakage Nonunion Salvage procedure Functional outcome
Introduction Proximal fractures of the femur represent an important cause of hospitalization, morbidity and mortality for elderly patients in industrialized countries [1]. Those fractures affecting the neck or head of the femur (AO/OTA 31B or C) are normally treated with an arthroplasty or osteosynthesis with cannulated screws. Otherwise, extra-articular fractures (AO/OTA 31A) are more commonly treated with osteosynthesis, mostly an intramedullary nail or a dynamic hip screw (DHS, Synthes, Solothurn, Switzerland). While both systems are recommended for stable fractures (AO/OTA 31A1), the intramedullary device is preferable for unstable fractures (AO/OTA 31A2–31A3) [2].
* Corresponding author at: Passeig Maritim 25-29, 08003 Barcelona, Spain. Tel.: +34 932480000; fax: +34 932483254. E-mail address: [email protected] (M. Cruz-Sa´nchez). http://dx.doi.org/10.1016/j.injury.2014.12.003 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
The biomechanical advantage of the nail with regard to the DHS is related to its position which is nearer to the weight-bearing axis. When the intramedullary system is compared with the extramedullary device, there is up to a 30% reduction of bending stresses [3]. A decrease in the blood loss and the periostium preservation are other advantages related to the minimal approach needed to place an intramedullary nail [4]. For these reasons, the number of these fractures treated with an intramedullary nail has been increased in the last decade, even for stable fractures [5]. Breakage of the intramedullary nail is an uncommon complication. The causes of this breakage are related to variables depending on the patient (osteoporosis, and associated morbidity) and others depending on the surgery (incorrect implant positioning or poor fracture reduction) [6]. The implant failure usually occurs when the fracture does not achieve the consolidation. Management of this complication includes conversion to total hip arthroplasty (THA) [7,8] or osteosynthesis revision [9]. Different authors have observed that most of these failures occur at the
M. Cruz-Sa´nchez et al. / Injury, Int. J. Care Injured 46 (2015) 729–733
730
intramedullary nail hole performed to cross the cervical screw [6,9]. However, the low number of patients included in these series make difficult to obtain conclusions and get a consensus related to the best practices in the management of this complication. The purpose of this study was to determine the prevalence, possible causes and management of this complication as well as the final functional outcomes of these patients in our hands. For this reason it was contemplated a large series of cases operated during 10 years in a single centre. Material and methods Retrospective study includes all patients operated for proximal femoral fractures with an intramedullary nail from January 2003 to December 2012 in a single department. A total of 1246 fractures were assessed, 573 men and 673 women, with a mean age of 82.3 years (range 51–101). Mean follow-up of these 1246 patients was 13 months (range 3–108). In most cases (1117) a Gamma 31 system (Stryker Trauma, Germany) was used. The other implants used were: 52 Affixus1 (DePuy Orthopedics, USA), 14 LNS-GT1 (Surgival, Spain) and 63 PFNA1 (Synthes, Solothurn, Switzerland). In all cases an antibiotic prophylaxis was performed and in most cases spinal anaesthesia was used. The surgical technique used in all cases was similar: the patient was placed in a traction table (Maquet1) to obtain a reduction of the fracture under fluoroscopic control. All nails were implanted by a 5 cm wound incision proximal to the trochanter. The decision of using a cervical-diaphyseal angle of 1258 or 1308 depended on the surgeon criteria. In all cases distal locking with 1 or 2.5-mm screw was done. Eleven cases out of 1246 presented an implant rupture (0.88%) at final follow-up. The initial fractures of these 11 cases were classified following the AO/OTA classification. Osteoporosis was also assessed following the Singh classification [10]. In Table 1 the epidemiological data of these patients, type of fracture, nail used in each case, time until the implant rupture, location where the nail failed and treatment is shown. In these 11 patients the mean follow-up was 36 months (range 12–96). A radiological study of these 11 patients was assessed after the first procedure using the Picture Archiving and Communication System (Centricity PACS-IW GE Healthcare1). For this, the suggestions of Lobo-Escolar et al. were followed for these types of osteosynthesis [11]. On the anteroposterior view different parameters were evaluated; the distance from the tip of the lag screw to femoral apex (in mm), Parker’s ratio [12], cervical-diaphyseal angle and fracture diastasis (in mm). On the lateral view, the position of the lag screw was assessed considering that this position was posterior if the ratio was 0.66 [12,13]. Different surgical salvage procedures were used in these 11 cases depending on the type of previous fracture, quality of the remaining bone as well as the surgeon criteria. In these patients the
Barthel score in the preoperative and postoperative period of the salvage surgery was also assessed as well as the SF-12 score at the final follow-up. Statistics Statistical analysis was performed by using the SPSS version 15.0 (SPSS Inc., Chicago, IL) statistical package. Continuous variables are presented as mean and standard deviation or range and categorical variables as percentages. A bivariant analysis of all radiological or clinical factors potentially associated with nail breakage was performed. Pearson’s correlation test was used for categorical variables. Throughout the statistics analysis the p value set at 3 mm) might be related to a
Fig. 1. The three different types of implant breakage.
Fig. 2. Treatment of the cervicocephalic screw breakage.
732
M. Cruz-Sa´nchez et al. / Injury, Int. J. Care Injured 46 (2015) 729–733
Fig. 3. Case treated with long nail due to a proximal aperture nail breakage.
lack of healing of the fracture overloading the nail and leading to its breakage. The reported prevalence of this complication ranged from 0.2 to 5.7% [6,14–16]. As far as we know, A´lvarez et al. [6] reviewed the largest series of implant breakage following this procedure. In this series, they found 5 cases of implant breakage in 843 cases operated during 12 years in a single centre. In the series that we present here, this complication has been identified in the 0.88% of cases in a large series including 1246 patients operated in a single centre. All fractures that presented this complication were initially classified as unstable fractures. All of them were presented as nonunion at the fracture site at the last follow-up previous to the implant breakage. The cause may be related to the fact that any nail can resist a specific number of cycles and the lack of healing at a
certain time might cause an implant failure [6,17,18]. In accordance with other series [15,17,19] the implant breakage takes place from 3 months to 2 years after the surgery. In our series this moment occurred at 11 months after the surgery. It is known that not achieving an optimal fracture reduction could lead to nonunion of the fracture [11]. In all cases, the distance between both fragments exceeds 3 mm, although, in most of cases, the position of the nail was acceptable in both antero-posterior and axial radiological view. It could be recommended that, in those patients with persistent pain at 6 months of follow-up with a suboptimal reduction and lack of consolidation signs, to consider dynamisation of the intramedullary device to avoid the implant breakage. In the largest published series [6,17], most of implant failure occurred in the proximal aperture of the nail. This point could be
Fig. 4. Method used for removal of the implant.
M. Cruz-Sa´nchez et al. / Injury, Int. J. Care Injured 46 (2015) 729–733
733
on the patient status, the remaining bone stock in the femoral head and the surgeon preferences.
Conflict of interest Authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.
References
Fig. 5. Case at 1 year postoperative of proximal nail aperture treated with 958-DCS.
considered as the weakest point of the nail where forces come from the pelvis and are transmitted to the lower part of the nail. In fact, an incorrect placing of the cervical screw may cause erosion of the nail in this position [20]. In the series presented, this complication has been observed in other 2 points of the implant: 3 cases in the cephalic screw and 1 case at the distal aperture of the nail [6,21,22] (Fig. 2). Distinctively to other series described in literature, 3 cases of breakage at the cephalic screw were observed. These ruptures were observed at the beginning of the screw threads. It could be thought that this is the weakest point of the screw. The therapeutic decision-making was mostly influenced by the remaining bone stock at the femoral head and the location of the initial fracture. It was considered that those patients who suffered a cephalic screw rupture had to be treated only with salvage procedure, an arthroplasty. In our series the remaining type of implant breakages were treated with a new osteosynthesis (DCS Synthes, Solothurn, Switzerland vs long nail Gamma3, Stryker Trauma, Germany) due to an acceptable bone stock at the femoral head. In the literature [17] most of cases with similar implant breakage were treated using an arthroplasty. It might be that it is difficult to remove the broken nail. For this, different methods and surgical procedures have been described in the literature in order to facilitate the implant removal [23,24] (Fig. 4). Functional scores and quality of life scores recorded in these 11 patients showed that these patients maintain an acceptable functionality and quality of life at the final follow-up. Patients who had suffered a proximal femoral fracture at same socio demographic background shown a similar result at 1 year follow up (Barthel: 72,63, SF-36: MCS 40.8, PCS 40.24) [25]. Although this are the longest case-series with this complication, the fact of having 11 patients make it difficult to take conclusions about the functionality of these patients after these procedures. In addition, it was difficult to consider all patients as a homogeneous group because the status of each patient previous to the initial fracture was quite different. Nevertheless, as far as we know, this is the first study including functional and quality of life test for patients who suffered this complication. Regarding to the limitations, this is a retrospective study due to the low frequency of this complication and all the conclusions should be interpreted with caution. In conclusion, the prevalence of this complication in this large series is 0.88%. Different treatments may be considered depending
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