Do we need a proximal femoral nail ?

Do we need a proximal femoral nail ? Mr Chris Oliver DM, FRCS (Tr & Orth), FRCP, DMI RCSEd Consultant Orthopaedic Trauma Surgeon Edinburgh Orthopaedic Trauma Unit Edinburgh, Scotland

Edinburgh Orthopaedic Trauma Unit

800,000 people local

tertiary referrals from 1.5 million

5500+ operations per year

45,000+ out-patients per year

50% of unit workload concerns orthogeriatric fractures

1000+ proximal femur fractures per year

PFN last year - zero!

Modern hip nailing systems IMHS: 1990 Richards PFN:1995 Stratec Gamma: 1989 Howmedica

Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur

Prospective, randomised controlled clinical trial with observer blinding.

400 consecutive patients 399 followed-up to one year or death.

Short-type Gamma nail (203 patients) or Richard's SHS (197 patients).

Outcome measurements were fixation failure and reoperation.

Functional outcome; pain, mobility status, range of movement were assessed until one year.

Adams CI, Robinson CM, Court-Brown CM, McQueen MM.

J Orthop Trauma. 2001 Aug;15(6):394-400.

Revision Gamma nail group 6%, Richard's group 4% p = 0.29

One subcapital femoral fracture in the Richard's group.

Femoral shaft fractures Gamma nail group (2%) none in the Richard's group (p = 0.13). Three required revision to another implant.

Lag-screw cut-out Gamma nail group (4%) Richard's group (2%) p = 0.37

Postoperative complications - same.

No difference functional status at one year.

“ The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications”.

“ Routine use of the Gamma nail cannot be recommended over the current standard treatment of dynamic hip screw and plate”.

Implant-related fractures of the femur following hip fracture surgery

Internal fixation or prosthetic replacement of the femoral head increases the risk of a later femoral fracture in susceptible osteoporotic patients.

Analyze the incidence of and risk factors for implant-related fractures of the femur after previous hip fracture surgery.

January 1988 to December 1997, 6230 patients (median age, eighty-two years; male: female ratio, 1247:4983) who sustained a total of 6696 hip fractures

Prospective study

Robinson CM, Adams CI, Craig M, Doward W, Clarke MC, Auld J.

J Orthop Trauma. 2001 Aug;15(6):394-400

141patients sustained an ipsilateral fracture of the femur at a median of twenty-four weeks following the original hip fracture surgery.

Survivorship analysis of the hip fracture population revealed an overall rate of subsequent femoral fracture of 2.9% at five years, which increased to 5.1% at ten years.

2/3 fractures propagated from tip of the implant.

Analysis of the subsequent fractures according to the type of implant used to treat the original fracture revealed considerable differences in incidence.

The incidence # per 1000 person years

Gamma nail 18.74

Cementless hemiarthroplasty 11.72

Compression hip screw 4.46

Cannulated screws 4.50

Primary arthroplasty with cement 6.2

Arthroplasty with cement as a revision procedure following failure of a primary implant 22.39

“ Implant-related fractures following hip fracture surgery are more common than has previously been appreciated”.

“ Risk of later ipsilateral femoral fracture is increased by the use of a Gamma nail or a cementless hemiarthroplasty to treat the original hip fracture”.

Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail - K Khan (data in press)

Unit concept

“ Span the femur and prevent periprosthetic fractures”

Prospective study

Mortality, functional outcome and complications

302 patients February 1994 to December 2001 (median age 78.5 )

Inclusion

Subtrochanteric fracture

Low-energy trauma (fall from standing height or below)

Exclusion criteria

High-energy injuries

Pathological fractures due to metastatic tumour

Initial cohort of 302 patients

74 patients died (24.5% mortality at 1 year)

10 patients: untraceable

7 patients: refused to participate

211 patients: Follow-up to 1 year

Peri-operative complications: 70 patients (23.2%)

43 (14.2%) treated non-operatively

27 (8.9%) required further surgery

18 required revision of the nail

Survivorship analysis Long Gamma Nail revised in 7.1%

Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail

Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Union

96.8% union at 6 months

7 patients: nail removed for suspected non-union

3 fractures: united, no further action

4 fractures: non-union confirmed, nail revised

Nail breakage (1 patient): non-union

Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Complications

Lag screw failure - 12 patients

Lag screw cut-out (9)

Lag screw penetration into acetabulum (1)

Lag screw back out (2)

AVN of femoral head (without cut-out)

Revised to long stem cemented THR

Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Metaphyseal fracture

Fracture distal to the tip of the nail (5)

All elderly females - Osteoporosis

Marked bowing of femur

Nail abutting anterior cortex (x-ray)

Exchange nail (modified) & cerclage wire

Protrusion of nail tip through anterior cortex during insertion (2 cases)

Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail Nail shape

Edinburgh Long Gamma Nail - Functional outcome

Increased social dependence

209 patients living in their own home prior to injury

Edinburgh Long Gamma Nail - Walking ability

178 patients were initially independent ambulators

Edinburgh Long Gamma Nail - Walking aids

158 initially walked without aids

Edinburgh Long Gamma Nail - Pain

Versatile treatment option for elderly population

“ Spans femur” but does have problems

Acceptable rate of complications

Satisfactory functional outcome considering pre-morbid status

Now using Gamma 3

Edinburgh Orthopaedic Trauma Unit - Long Gamma Nail

Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures.

Meta-analysis eighteen trials comparing the Gamma nail with the SHS were included, with data available for 2575 patients.

“ Given the lower complication rate of the SHS in comparison with Intramedullary nails, it appears that the SHS is superior for trochanteric fractures”