The Holland nail: a universal implant for fractures of the proximal femur and the femoral shaft

Surgical management of bifocal femoral fractures: a systematic review and pooled analysis of treatment with a single implant versus double implants

INTRODUCTION

Fractures of the proximal femur accompanied by a fracture of the femoral shaft are relatively rare, with a reported prevalence between 1 and 12%. Multiple surgical options are available, consisting of treatment with a single implant or with double implants. Controversy exists about the optimal management. A systematic review and pooled analysis were performed to assess the most reliable treatment for bifocal femoral fractures of the femur.

MATERIALS AND METHODS

A literature search was conducted on July 15, 2022. Selected studies were screened on title and abstract by two researchers independently, and full texts were read by both authors. Emphasis was put on adverse events such as postoperative infection, healing complications, malalignment, and functional outcome using either a single implant or double implants.

RESULTS

For the proximal femoral fractures, no significant difference could be confirmed for avascular necrosis of the femoral neck (5.1% for single implant and 3.8% for double implants), nonunion (6.4% for single implant and 7.8% for double implants), or varus malalignment (6.6% for single implant and 10.9% for double implants). This study also suggests that the number of implants is irrelevant for complications of the femoral shaft regarding the rates of postoperative infection and healing complications. Pooled rates of bone healing complications were 1.6-2.7-fold higher when patients were treated with a single implant, but statistical significance could not be confirmed. For hardware failure, revision surgery, leg length discrepancy, and functional outcome, no difference between the two groups was found either.

CONCLUSIONS

The pooled proportions of all postoperative complications had overlapping confidence intervals; thus, no inference about a statistically significant difference on the number of implants used for treating ipsilateral fractures of the femur can be made. Both treatment groups showed a similar functional outcome at the last moment of follow-up, with more than 75% of the patients reporting a good outcome.

Ipsilateral proximal and shaft femoral fractures treated with bridge-link type combined fixation system

BACKGROUND

Although many treatments for ipsilateral proximal and shaft femoral fractures have been developed, controversy exists regarding their optimal management. The purpose of this retrospective study was to discuss the effectiveness of the bridge-link type combined fixation system (BCFS) and evaluate functional outcomes in treating patients with these complex fractures.

PATIENTS AND METHODS

We retrospectively reviewed 14 cases of ipsilateral proximal and shaft femoral fractures treated from January 2012 to December 2016. All cases were treated by BCFS combined with minimally invasive percutaneous plate osteosynthesis (MIPPO). Clinical and radiographic data were collected during regular post-operative follow-up visits. Functional outcomes were determined according to the Friedman and Wyman scoring system.

RESULTS

The proximal femoral fractures were emergency diagnoses in 11 cases and delayed diagnoses in 3 cases. The delay time was 5-6 days, with an average of 5.3 days. The mean operation time was 179.6 min (range 135-231 min) with a blood loss volume that ranged from 430 to 535 ml (average 483.6 ml). Follow-up was conducted in 13 cases between 9 and 30 months post-operation, with an average follow-up time of 17.3 months. The proximal femoral fractures were united in 12 cases at the final follow-up. One case had nonunion 13 months after the operation, underwent valgus intertrochanteric osteotomy, and healed 6 months later. The femoral shaft fractures obtained rigid union at the latest follow-up in 12 cases. One case endured nonunion 12 months after the operation. After the revision surgery and iliac bone grafting, the fracture healed 6 months later. Eight of the cases had good functional results, 4 had fair results, and results were poor in 1 case at the final follow-up.

CONCLUSIONS

The treatment of ipsilateral proximal femoral and shaft fractures with BCFS in combination with MIPPO demonstrated a high likelihood of union for both fractures and good functional results.

Outcome after fixation of metastatic proximal femoral fractures: A systematic review of 40 studies

Endoprosthetic reconstruction, intramedullary nailing, and open reduction internal fixation (ORIF) are the most commonly practiced surgical strategies for treatment of metastatic proximal femoral fractures. This review describes functional outcome, local, and systemic complications. All three surgical strategies result in reasonable function on average; however, wide ranges indicate that both poor and good functional levels are obtained. We found that the overall reoperation rate was comparable for endoprosthesis and intramedullary nailing, but was higher for ORIF. J. Surg. Oncol. 2016;114:507-519. © 2016 Wiley Periodicals, Inc.

Intramedullary fixation of pertrochanteric fractures after hip resurfacing arthroplasty - Do we have the answer? Case report and literature review

OBJECTIVE

To report a case of a peri-prosthetic hip fracture fixed using a previously unreported technique of intramedullary nailing with dual proximal fixation.

CASE SUMMARY

An 81-year-old nursing home resident suffered a multi-fragmentary peri-prosthetic hip fracture around a Birmingham Hip Resurfacing arthroplasty (BHR), which was fixed using a novel technique.

DISCUSSION

Such fractures pose a significant surgical dilemma with regards to the optimal method of treatment. The increasing popularity of these implants suggests that these fractures will become increasingly common.

CONCLUSION

We believe that our technique provides a practical and satisfactory solution to these fractures.

Biomechanical analyses of static and dynamic fixation techniques of retrograde interlocking femoral nailing using nonlinear finite element methods

Femoral shaft fractures can be treated using retrograde interlocking nailing systems; however, fracture nonunion still occurs. Dynamic fixation techniques, which remove either the proximal or distal locking screws, have been used to solve the problem of nonunion. In addition, a surgical rule for dynamic fixation techniques has been defined based on past clinical reports. However, the biomechanical performance of the retrograde interlocking nailing systems with either the traditional static fixation technique or the dynamic fixation techniques has not been investigated by using nonlinear numerical modeling. Three-dimensional nonlinear finite element models were developed, and the implant strength, fixation stability, and contact area of the fracture surfaces were evaluated. Three types of femoral shaft fractures (a proximal femoral shaft fracture, a middle femoral shaft fracture, and a distal femoral shaft fracture) fixed by three fixation techniques (insertion of all the locking screws, removal of the proximal locking screws, or removal of the distal locking screws) were analyzed. The results showed that the static fixation technique resulted in sufficient fixation stability and that the dynamic fixation techniques decreased the failure risk of the implant and produced a larger contact area of the fracture surfaces. The outcomes of the current study could assist orthopedic surgeons in comprehending the biomechanical performances of both static and dynamic fixation techniques. In addition, the surgeons could also select a fixation technique based on the specific patient situation using the numerical outcomes of this study.

A comparison of intramedullary nailing and plate-screw fixation in the treatment for ipsilateral fracture of the hip and femoral shaft

We compared the outcomes of intramedullary nailing with plate-screw fixation in the treatment for ipsilateral fracture of the hip and femoral shaft. A retrospective study. Level 1 Trauma. Forty-one patients (32 males and 9 females; mean age, 34 years; age range, 21-53) with ipsilateral hip and femoral shaft fractures were treated between 1995 and 2005. Eighteen patients were injured in motor vehicle accidents, and 23 fell from a height. All patients were treated by one of the two methods of internal fixation: a screw-plate fixation (n = 24, Group I) or intramedullary nailing (n = 17, Group II). The fracture union time, nonunion, delayed union, implant failure, need of further surgeries, and functional outcomes were investigated and compared. Fisher's exact test showed that Group I had a significantly higher frequency of nonunion than that of Group II (P = 0.029). Although Group I had more nonunions, delayed unions, and revision operations than Group II, the total union time was similar for both groups. Intramedullary nailing was found to be superior to screw-plate fixation due to improved functional bearing, increased rate of union, stability, and mechanical solidity. The reconstruction nail method is an acceptable alternative treatment for ipsilateral hip and femoral shaft fractures.

Occurrence of secondary fracture around intramedullary nails used for trochanteric hip fractures: a systematic review of 13,568 patients

INTRODUCTION

A sliding hip screw (SHS) is currently the treatment of choice for trochanteric hip fractures, largely due to the low incidence of complications. An alternative treatment is the use of intramedullary proximal femoral nails. Unfortunately these implants have been associated with a risk of later fracture around the implant. The aim of this study was to see if any improvements have been made to the current intramedullary nails, to reduce the incidence of secondary fracture around the distal tip of the nail.

METHODS

We analysed data related to 13,568 patients from 89 studies, focusing on the incidence of post operative secondary femoral shaft fracture following the use of intramedullary nails in the fixation of trochanteric hip fractures.

RESULTS

The overall reported incidence of secondary fracture around the nail was 1.7%. The incidence of fracture has reduced in the 3rd generation Gamma nails when compared to the older Gamma nail (1.7% versus 2.6%, p value 0.03). However, the incidence of secondary fracture in the 3rd generation Gamma nails is still significantly higher than the other brands of short nail (1.7% versus 0.7%, p value 0.0005). Long nails had a slight tendency towards a lower risk of fracture although the difference was not statistically significant (1.1% versus 1.7%, p value 0.28). There was a significantly lower risk of fracture for those nails with a biaxial fixation as opposed to uniaxial fixation (0.6% versus 1.9%, p value <0.0001).

CONCLUSION

Secondary fracture around a proximal femoral nail is one of the most significant of fracture healing complications, and this study suggests that continuing design changes to this method of fixation has reduced the risk of this complication occurring.

3066 consecutive Gamma Nails. 12 years experience at a single centre

Background

Fixation of trochanteric hip fractures using the Gamma Nail has been performed since 1988 and is today well established and wide-spread. However, a number of reports have raised serious concerns about the implant's complication rate. The main focus has been the increased risk of a subsequent femoral shaft fracture and some authors have argued against its use despite other obvious advantages, when this implant is employed.

Through access to a uniquely large patient data base available, which is available for analysis of trochanteric fractures; we have been able to evaluate the performance of the Gamma Nail over a twelve year period.

Methods

3066 consecutive patients were treated for trochanteric fractures using Gamma Nails between 1990 and 2002 at the Centre de Traumatologie et de l'Orthopedie (CTO), Strasbourg, France. These patients were retrospectively analysed. Information on epidemiological data, intra- and postoperative complications and patients' outcome was retrieved from patient notes. All available radiographs were assessed by a single reviewer (AJB).

Results

The results showed a low complication rate with the use of the Gamma Nail. There were 137 (4.5%) intraoperative fracture-related complications. Moreover 189 (6.2%) complications were detected postoperatively and during follow-up. Cut-out of the lag screw from the femoral head was the most frequent mechanical complication (57 patients, 1.85%), whereas a postoperative femoral shaft fracture occurred in 19 patients (0.6%). Other complications, such as infection, delayed healing/non-union, avascular femoral head necrosis and distal locking problems occurred in 113 patients (3.7%).

Conclusions

The use of the Gamma Nail in trochanteric hip fractures is a safe method with a low complication rate. In particular, a low rate of femoral shaft fractures was reported. The low complication rate reported in this series can probably be explained by strict adherence to a proper surgical technique.

Ipsilateral basicervical femoral neck and shaft fractures treated with long proximal femoral nail antirotation or various plate combinations: comparative study

BACKGROUND

Although many treatment methods have been developed, controversy exists regarding the optimal management of ipsilateral femoral neck and shaft fractures. The purpose of this retrospective study was to compare the results of long proximal femoral nail antirotation (PFNA-long) and various plate combinations in the treatment of ipsilateral basicervical femoral neck and shaft fractures.

METHODS

Between January 2004 and May 2008, a total of 21 patients with ipsilateral basicervical femoral neck and shaft fractures were treated with PFNA-long or various plate combinations. We divided patients into two groups. Group I included 11 patients who underwent surgery with cancellous lag screws or dynamic hip screws (DHS) combined with compression plate fixation. Group II included 10 patients who underwent surgery with PFNA-long.

RESULTS

The average follow-up periods were 22.2 and 20.8 months for groups I and II, respectively. The average union times for femoral neck fractures in groups I and II were 15.6 and 16.0 weeks, respectively; and the average union times for shaft fractures were 21.1 and 20.3 weeks, respectively. There were eight good, two fair, and one poor functional result in group I and eight good, one fair, and one poor in group II. One case of implant failure and nonunion of the femoral shaft fracture occurred in group I. There were no significant differences in the functional outcomes or major complications between the two groups.

CONCLUSIONS

Both treatment methods achieved satisfactory functional outcomes in patients with ipsilateral basicervical femoral neck and shaft fractures. PFNA-long was a good option for the treatment of complex fractures, with the advantages of closed antegrade nailing with minimal exposure, reduced perioperative blood loss, and biological fixation of both fractures with a single implant.

The biomechanics of ipsilateral intertrochanteric and femoral shaft fractures: a comparison of 5 fracture fixation techniques

OBJECTIVES

The aim of the present study was to examine biomechanically 5 different construct combinations for fixation of ipsilateral intertrochanteric and femoral shaft fractures.

METHODS

Twenty-five fresh-frozen adult human femora (age range = 58-91 years, average age = 75.4 years) were tested in physiological bending and in torsion to characterize initial bending and torsional stiffness and stiffness following fixation of combined intertrochanteric and femoral shaft fractures. Five fracture fixation device constructs were assessed-construct A: long dynamic hip screw (long DHS); construct B: reconstruction nail; construct C: DHS plus low-contact dynamic compression plate; construct D: DHS plus retrograde intramedullary nail; and construct E: long intramedullary hip screw. Axial stiffness, torsional stiffness, and axial load-to-failure were the main measurements recorded.

RESULTS

There were no differences between constructs in terms of axial stiffness (P = 0.41), external rotation stiffness (P = 0.13), and axial load-to-failure (P = 0.16). However, there was a borderline statistically significant difference in internal rotation stiffness between the constructs (P = 0.048). Specifically, construct C was significantly stiffer than construct E (P = 0.04).

CONCLUSIONS

All constructs showed no statistical differences when compared with one another, with the exception of construct E, which provided the least torsional stiffness. However, the current in vitro model did not simulate fracture healing or support offered by soft tissues, both of which would affect the stiffness and load-to-failure levels reached.

Subtrochanteric fractures: current management options

PURPOSE

To review current management options for subtrochanteric fractures of the femur. These fractures behave differently from other proximal femoral fractures and have their own management pitfalls and problems.

METHOD

Articles were identified from Medline. Papers on the management of subtrochanteric fractures were assessed, and included if they contained relevant information. The articles were divided into groups depending on the type of management described. Conservative and operative management were considered separately. Operative management was classified according to the type of device used into extramedullary and intramedullary.

CONCLUSIONS

Conservative management gives satisfactory results in 56% of patients compared to 70 - 80% for operative methods. The studies on conservative methods are mostly dated, with less stringent outcome measures. Conservative management is safe, and has a low frequency of non-union. It is most applicable in regions where facilities are suboptimal, in patients unfit for surgery, and in children. When considering operative management, intramedullary devices appear to give better results than extramedullary devices, particularly when the medial buttress of the proximal femur is compromised. However, when operative treatment is undertaken, it should be by experienced surgeons using the technique with which they are most familiar.