Cephalomedullary interlocked nail for ipsilateral hip and femoral shaft fractures

Injury, Int. J. Care Injured (2004) 35, 1031—1038 Cephalomedullary interlocked nail for ipsilateral hip and femoral shaft fractures Pankaj Jain*, Lalit Maini, Puneet Mishra, Ashish Upadhyay, Ajay Agarwal Department of Orthopaedics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi 110002, India Accepted 17 September 2003 KEYWORDS Cephalomedullary nail; Ipsilateral hip; Femoral shaft fractures Summary A retrospective study of the management of 23 cases of ipsilateral hip and femoral shaft fractures, between January 1998 and December 2001, is presented. All except two cases were managed by a single implant, i.e. reconstruction nail. There was delayed diagnosis of femoral neck fracture in two cases where the ‘‘miss a nail’’ technique was used for fixation of the femoral neck fracture. All patients managed by reconstruction nail were simultaneously operated on for both fractures and operative treatment was executed as early as the general condition of the patient permitted. Delay in treatment was generally because of the associated injuries (head, chest or abdominal). There were 22 males and 1 female patient with an average age of 34.5 years. Average follow-up was 30.9 months. There was one case of non-union of the femoral neck fracture, one case of avascular necrosis and one femoral neck fracture united in varus. There were four cases of non-union and six cases of delayed union of femoral shaft fractures. Mean time for union of the femoral neck fracture was 15 weeks and for the shaft fracture was 22 weeks. In this series femoral shaft fracture determined the total union period. Complications involving the femoral shaft fracture were more common than those related to femoral neck fractures. Shaft complications were more manageable with or without secondary procedures as compared to femoral neck complications, which usually require more extensive procedures. This stresses the need to realise the significance and seriousness of both components of this complex injury, in evaluation, management and post-operative care. We conclude that, though technically demanding, reconstruction nail is an acceptable alternative for management of concomitant fractures of the femoral neck and shaft with acceptable rates of complications and good results. ß 2003 Elsevier Ltd. All rights reserved. Introduction *Corresponding author. Present address: H-272, R.K. Apartments, I.P. Extension, Delhi 110092, India. Tel.: þ91-11-22516481. E-mail address: drjainpan@hotmail.com (P. Jain). Ipsilateral fractures of the femoral neck and shaft are rare and are usually encountered in high-energy injuries.5,6,22 This is a combination of injuries that present diagnostic difficulties and complex treatment choices. Since reported initially, treatment of 0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.09.039 1032 Figure 1 X-ray showing reconstruction nail with fracture neck of femur united. this combination of injuries is still in evolution.9 There are nearly 60 different recommended methods for managing these concurrent fractures yet no single method can be considered standard or, even preferable.6,18,22 Many of these patients are polytrauma victims and once the initial concern of preservation of life is fulfilled, focus should change towards early management and rehabilitation of the patient. This paper reports our experience of managing 23 such cases, mainly by second-generation interlocking nail or reconstruction nail by a closed technique (Fig. 1). Materials and methods Between January 1998 and December 2001, we treated 250 patients with femoral shaft fractures, of which 23 sustained ipsilateral hip and femoral shaft fractures. The incidence of this complex injury was thus 8% (23/250) in our series. There were 22 males and 1 female patient (Table 1). Age P. Jain et al. ranged from 21 to 56 years (mean 34.5 years). All these injuries followed high-energy trauma; 18 patients were injured in a road traffic crash (14 in an automobile and 4 in an automobile—pedestrian crash, who were hit from behind) and 5 by a fall from height. Diagnosis of a fractured neck of femur was initially missed in two cases. Nine patients had other associated life threatening organ system injuries (head, abdominal and chest). Thirteen patients had other associated fractures in the upper or lower extremities or thoraco-lumber spine (Table 2). There were 19 cases of intracapsular femoral neck fracture of which 2 were subcapital fractures, 7 were transcervical and 10 were basicervical. Both subcapital fractures were undisplaced (missed initially), but 9 of 17 fractures in the transcervical and basicervical group were displaced. There were four cases of simple, non-comminuted intertrochanteric fractures, which were displaced in three of the four cases. Femoral shaft fractures were more common in the middle-third (13/23), four being in proximal third (4/21) and five in distal third (5/21). There was one segmental femoral shaft fracture. There were four compound fractures–—two cases of Types 1 and 2 of Type 2 (Gustilo Anderson). Comminution of the shaft fracture was categorised according to the Winquist and Hansen classification: there were three cases of grade 1; six cases of grade 2; six cases of grade 3; and seven cases of grade 4 (Table 1). Twenty of the 23 shaft fractures were unstable which included Winquist types 2, 3, 4, segmental and spiral shaft fractures. Management protocol Management of these injuries was strictly according to the ATLSÕ protocol. Primary survey was aimed at resuscitation of the patient. After initial resuscitation, secondary survey was aimed towards definitive and rehabilitative care. Once stabilised, the patient was placed supine on the fracture table and closed reduction of the femoral neck and shaft fracture attempted. The guide wire was introduced next negotiating the femoral fracture followed by cephalomedullary nail. Reduction of the femoral neck fracture was then rechecked under C-arm and the proximal locking was done. Lastly distal locking was done. Post-operative management Patients were permitted early non-weight bearing mobilisation with gradual range of motion exercises. Partial weight bearing was advised after 8 weeks. Full weight bearing was permitted only after Cephalomedullary interlocked nail Table 1 1033 Patient profile S.no. Age Sex Side Hip fracture Shaft femur fracture Associated injury 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 M M M M M M M M M M M M M M M M F M M M M M M R R R R L L R L R R R L R L R L R R R R R R L Transcervical Intertrochanteric Basicervical Transcervical Intertrochanteric Transcervical Transcervical Intertrochanteric Transcervical Intertrochanteric Subcapital Basicervical Basicervical Basicervical Subcapital Basicervical Basicervical Transcervical Basicervical Transcervical Basicervical Subcapital Subcapital Middle-third WH-1 Distal third WH-II, Gr-2 Middle-third WH-I Middle-third WH-II Middle-third WH-IV, Gr-2 Distal third WH-III Middle-third WH-III Proximal third WH-I Middle-third WH-II Proximal third WH-IV Middle-third WH-III Middle-third WH-IV Distal third WH-III Distal third WH-IV Proximal third WH-II Middle-third WH-IV Middle-third WH-II, Gr-1 Distal third WH-IV Segmental Proximal third WH-III, Gr-1 Middle-third WH-IV Middle-third WH-II Middle-third WH-III # Both bones forearm (R), head injury Compd # patella R, # pelvis, # D10—12 Nil Nil # Both bones forearm (L), I/C (L) knee Intercondylar tibia # (L) Ankle # (L), chest injury Both bones leg # (L) Nil Nil Distal radius #, chest injury Intercondylar tibia # (L) Nil I/C humerus (L), abdominal injury # Patella, head injury ACL (L) knee Humerus #, head injury MCL (R) knee, abdominal injury Nil Abdominal injury I/C humerus (R), head injury Nil Nil 37 42 38 26 21 40 25 35 27 45 45 18 30 27 29 32 33 41 56 38 39 40 29 WH, Winquist and Hansen; D, dorsal vertebra; Gr, grade (Gustilo Anderson); I/C, intercondylar; #, fracture; ACL, anterior cruciate ligament; MCL, medial collateral ligament. appearance of bridging callus or clinical union. Quadriceps strengthening, and knee range of motion exercises were also encouraged. Patients were followed up monthly after suture removal for 6 months, bimonthly till 1 year and trimonthly after 1 year. Status of fracture healing and progress in recovery were recorded. Radiological follow-up for avascular necrosis was continued till a minimum of 1 year. Results Our average follow-up was 30.9 months (range 12— 55 months). Femoral neck fracture was initially missed in two of our patients. It was diagnosed after intramedullary nailing was completed so these cases were then managed with ‘‘miss a nail’’ technique with two screws inserted in the head. In all other 21 cases, closed reconstruction nailing was performed. A single screw in the femoral head was inserted in 2 cases, two screws in the femoral head were used in 17 cases and three screws in the femoral head in 2 cases. Average operative time was 4 h (range 2.30—5.00 h). Average blood loss was approximately 600 ml (range 350—950 ml). Though all cases were operated on as early as the general condition of the patient permitted, average interval from injury to internal fixation was 5 days (range 1— 14 days). Results of femoral neck fractures There was one non-union, three cases of delayed union (uniting around 10 months), and one case of aseptic necrosis showing early signs around 1 year. One fracture united in varus (Fig. 2). There was no case of infection. Time for union of femoral neck varied from 14 to 42 weeks (average 15 weeks). Results of femoral shaft fractures There were four cases of non-union of shaft femur, six cases of delayed union (uniting around 9 months), one case of infection and one case of implant failure (distal locking screw breakage). Overall limb shortening was <2.5 cm in four cases (contributed by coxa vara and collapse at femoral shaft fracture). Average time for union of the femoral shaft fracture (excluding non-union) varied from 16 to 36 weeks (average 22 weeks). All cases of non-union were supplemented with bone grafting and union was achieved in the following 3 months. 1034 Table 2 Treatment and follow-up Locking screws Proximal Distal Follow-up Union time (weeks) (months) Hip Shaft 2 2 2 2 2 2 2 2 2 2 3 2 2 3 1 2 2 2 2 2 2 2 2 2 2 2 1 1 2 2 2 1 2 2 1 2 2 2 1 1 2 2 2 2 1 1 48 36 38 23 28 16 17 24 26 24 18 26 24 24 23 21 29 18 16 13 12 25 36 14 42 16 24 22 38 18 18 16 14 12 18 16 12 12 16 14 40 14 16 15 15 18 18 16 28 20 16 18 18 32 14 16 26 20 32 20 30 30 20 24 Complications Proximal Distal AVN Nil Nil Nil Infection, delayed union Nil Non-union Nil Nil Nil Delayed union Nil Nil Delayed union Non-union, distal screw failed Nil Delayed union Nil Non-union Delayed union Delayed union Non-union Nil Nil Non-union Coxavara Knee, ROM (8) Hip ROM, F/E/Abd/Add/ER/IR (8) 0—100 0—80 0—130 0—80 0—100 0—100 0—120 0—130 0—120 0—100 0—120 0—100 0—100 0—120 0—120 0—100 0—130 0—100 0—120 0—130 0—120 0—130 1—130 0—80, 0—130, 0—130, 0—120, 0—130, 0—130, 0—130, 0—130, 0—130, 0—130, 0—130, 0—100, 0—120, 0—130, 0—130, 0—110, 0—130, 0—130, 0—130, 0—130, 0—120, 0—130, 0—130, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—10, 0—20, 0—40, 0—40, 0—40, 0—40, 0—40, 0—40, 0—40, 0—40, 0—40, 0—30, 0—30, 0—40, 0—40, 0—40, 0—20, 0—40, 0—40, 0—40, 0—40, 0—30, 0—40, 0—40, 0—20, 0—30, 0—30, 0—30, 0—30, 0—30, 0—30, 0—30, 0—30, 0—30, 0—30, 0—20, 0—30, 0—30, 0—30, 0—30, 0—30, 0—30, 0—30, 0—30, 0—20, 0—30, 0—30, 0—20, 0—40, 0—30, 0—40, 0—40, 0—30, 0—30, 0—30, 0—40, 0—30, 0—40, 0—30, 0—30, 0—40, 0—40, 0—20, 0—40, 0—40, 0—30, 0—40, 0—30, 0—40, 0—40, LLD 0—10 0—40 0—40 0—30 0—30 0—30 0—30 0—30 0—30 0—40 0—50 0—30 0—40 0—30 0—30 0—30 0—30 0—30 0—30 0—30 0—30 0—30 0—30 0 mm 1.5 cm 0 mm 0 mm 0 mm 0 mm 0 mm 0 mm 0 mm 0 mm 0 mm 1.5 cm 0 mm 0 mm 0 mm 1.5 cm 0 mm 0 mm 0 mm 0 mm 2.5 cm 0 mm 0 mm LLD, limb length discrepancy; F, flexion; AVN, avascular necrosis; E, extension; Abd, abduction; Add, adduction; IR, internal rotation; ER, external rotation. P. Jain et al. Cephalomedullary interlocked nail 1035 Functional results All healed hip fractures (except one with avascular necrosis) showed a good range of motion (Table 2). Knee stiffness was present in 10 cases with knee range of motion from 0 to 808 in 2 cases, 0 to 1008 in 8 cases. Knee stiffness was probably compounded by associated injuries around knee (Table 2). Fourteen patients were completely pain free, four patients complained of mild to moderate pain (after exertion)and only in two cases was pain moderate to severe. One patient with aseptic necrosis had to change his occupation as a chauffeur. All other patients were able to perform activities of daily living and returned to their earlier occupation. Technical complications Figure 2 X-ray showing fracture neck of femur united in varus. Figure 3 As this procedure has a learning curve, we faced several technical difficulties. Difficulty in establishing an accurate entry point for insertion of the nail was encountered in two cases. The entry point in these cases was in continuity with the fracture of the neck, leading to an anteromedial exit of the guide wire. Anatomical reduction of the femoral neck fracture was not satisfactorily achieved in two cases. Distraction of the proximal femoral fracture at nail insertion occurred in two cases. In two cases, misdirection of the proximal locking screws occurred, once anterior and once posterior (Fig. 3). This occurred due to rotational discrepancy between the proximal locking jig and the proximal X-ray showing misdirection of proximal screws. 1036 P. Jain et al. femur. This was recognized intra-operatively while confirming the satisfactory placement of proximal locking screws in the femoral head by taking lateral views under C-arm. After correcting the rotational alignment between the jig and the proximal fracture, the proximal locking screws were changed. In three cases, we were unable to perform distal locking in same sitting and delayed distal locking was required. These cases were polytrauma victims and had concomitant extremity fractures which also required early fixation to allow early patient rehabilitation. Hence in view of the prolonged operative time (around 4 h) and after suggestion from the anesthetist regarding the general condition of the patient, it was decided to defer distal locking in the same sitting. In two cases, nail was driven too far distally thereby allowing placement of only one proximal screw. The time taken for performing the procedure and the number of technical complications described correlates with the experience of the surgeon. Post-operative complications There were two cases of deep vein thrombosis occurring within 2 weeks following surgery. There was one infection, which required debridement and intravenous antibiotics for 2 weeks. Discussion A review of literature shows that nearly every method, device and their combinations have been used for management of this complex injury but no large series has reported the results utilising a single treatment modality or protocol.3,12,18 Also, there is a paucity of reports sharing experiences with management of this injury by reconstruction nail.2,4,5,8,19—21 Incidence of this injury pattern appears to be on the rise; it is 8% in our series as compared to 2.5—6% reported in the literature.13,21 Although the incidence of missed femoral neck fractures is around 13—31%, it was quite low (<10%, 2/23 cases) in our series probably because of awareness of this injury pattern and routine roentgenographic evaluation of the ipsilateral hip in all femoral shaft fractures.13,21 This complex injury pattern shows a high incidence of associated ipsilateral knee injuries especially patellar fractures and ligamentous injuries.9,15 In our series six cases had ipsilateral knee injuries. Patients with this injury should have both AP and lateral views and clinical examination of the knee, both pre and post-fracture fixation, for proper evaluation as these injuries have a bearing on the final outcome.3,6,13,21 Concomitant hip fractures in our series were usually undisplaced or minimally displaced and shaft fractures were usually unstable as per the particular mechanism of these injuries. The incidence of displaced proximal fractures (12/23) is also consistent to that reported in other series.3,6 There was only one case of non-union of a femoral neck fracture probably due to inadequate reduction of the fracture. The authors feel that inaccurate reduction rather than delayed fixation is responsible for non-union.3 Figure 4 X-ray showing avascular necrosis of femoral head. Cephalomedullary interlocked nail There was only one case of avascular necrosis (Fig. 4) that started showing signs with in 1 year of injury. The rate of avascular necrosis in this study is quite low compared to isolated femoral neck fractures at around 4%.3,6,7,21 The average time for femoral neck union was from 14 to 42 weeks (average 15 weeks) and the femoral shaft united in 16—36 weeks (average 22 weeks) which is consistent with that reported in other series. In our study the femoral shaft fracture determined the total union period, overall outcome and also the major share of complications.19,22 The three major issues related to these fractures are–—optimal timing of surgery, which fracture to be stabilised first and optimal implant to be used. In our experience, early fixation allows optimal intensive care, decreases morbidity and mortality, reduces complications of traction and recumbency and decreases health care costs.6,13 These combination of fractures can be dealt with in a delayed fashion22 but the time factor is much more important for early mobilisation and rehabilitation of the patient than for fracture union.13 Though there is confusion regarding which fracture should be managed first6,12,16,17 there appears to be a general consensus regarding the seriousness of complications involving the fractured femoral neck. Though osteonecrosis is the most disabling complication of fractured neck of femur, rates are lower in this combined injury3,6,21 and it is doubtful that delay in diagnosis and treatment increases the risk of osteonecrosis.21 Emergency fixation of the fractured neck of femur in this combined injury pattern, unlike isolated femoral neck fractures may be unnecessary.22 Reconstruction nail uses the advantage of both ideologies, i.e. stabilising the hip fracture and shaft fracture simultaneously and fixing them at the same time. As regards to the technique of reconstruction nailing, we have used the following protocol. After anaesthesia, the patient is placed supine on the fracture table. The proximal fracture is aligned using the maneuver of traction, abduction and internal rotation, and confirmed under the C-arm. After making the entry point at the tip of the greater trochanter, the guide wire is inserted and progressed to negotiate the shaft fracture. Once the shaft fracture is reduced and reamed, the recon nail is inserted and is followed by fixation of the femoral neck by proximal screws and lastly the nail is locked distally. The authors noted that substantial internal rotation has to be performed in order to reduce the hip fracture as anatomically as possible12 and initial stabilisation of the shaft fracture assists this manoeuvre.3 There is no optimal implant described for this complex injury. Various methods of fixation do 1037 not seem to alter the final outcome.3 Authors that have used reconstruction nails for management of these injuries have reported variable results.1,2,4,10,11,14,20 The authors feel that this procedure is technically demanding and has a learning curve. A reconstruction nail is advantageous in terms of possible closed antegrade nailing with a minimal incision, reduced blood loss; biological fixation of both the fractures,4,12 less chances of displacement of proximal fractures (as compared to retrograde nailing) and early rehabilitation of the patient.3 The main practical problem observed was difficulty in obtaining rotational alignment of the rod and inserting the proximal interlocking screws so that they engage the head. As suggested earlier, substantial internal rotation helps in reducing the hip fracture as anatomically as possible.12 The authors conclude that reconstruction nail is an acceptable implant for this combination of injury since both fractures could be reduced closed and fixed by a single technique. It provides optimal stability in these double fractures, controls angulation, shortening and rotation of femoral shaft and allows compression and impaction at the hip fracture site. With few complications, which can be minimised, it achieves the goal of anatomical reduction and stable fixation in this complex injury pattern. References 1. Alho A. Concurrent ipsilateral fractures of the hip and femoral shaft: a metaanalysis of 659 cases. Acta Orthop Scand 1996;67:19—28. 2. Alho A, Ekeland A, Grogaard B, Dokke JR. A locked hip screw-intramedullary nail (Cephalomedullary nail) for the treatment of the proximal part of the femur combined with fractures of the femoral shaft. J Trauma 1996;40(1):10—6. 3. Bennett FS, Zinar DM, Kilgus DJ. Ipsilateral hip and femoral shaft fractures. Clin Orthop 1993;96:168—77. 4. Bose WJ, Corces A, Anderson LD. A preliminary experience with the Russell—Taylor reconstruction nail for complex femoral fractures. J Trauma 1992;32(1):71—6. 5. Bucholz WR, Rathjen K. Concomitant ipsilateral fractures of the hip and femur treated with interlocking nails. Orthopedics 1985;8(II). 6. Casey MJ, Chapman MW. Ipsilateral concomitant fractures of the hip and femoral shaft. J Bone Joint Surg 1979;61(A). 7. Chen CH, Chen TB, Cheng YM, Chang JK, et al. Ipsilateral fractures of the femoral neck and shaft. Injury 2000;31: 719—22. 8. Chen CM, Chiu FY, Lo WH, Chuang TY. Ipsilateral hip and distal femoral fractures. Injury 2000;31:147—51. 9. Delaney WM, Street DM. Fracture of femoral shaft and fracture of neck of same femur: treatment with medullary nail for shaft and knowles pins for neck. J Int Coll Surg 1953;19:303—11. 10. Garnavos C, Peterman A, Howard PW. The treatment of difficult proximal femoral fractures with the Russel Taylor reconstruction nail. Injury 1999;30:407—15. 1038 11. Kraemer WJ, Hearn TC, Powell JN, Mahomed N. Fixation of segmental subtrochantric fractures. Clin Orthop 1996;332: 71—9. 12. Leung KS, So WS, Leung PC. Treatment of ipsilateral femoral shaft fractures and hip fractures. Injury 1993;24(1): 41—5. 13. Plancher KD, Donshik JD. Femoral neck and ipsilateral femoral shaft fractures in the young adult. Orthop Clin 1997;28(3). 14. Ramser JR, Mikhalo WM, Carr JB, Beaudoin AJ, Krause WR. A comparison of femoral neck fixation with the reconstruction nail versus cancellous screws in anatomical specimens. Clin Orthop 1993;290:189—96. 15. Ritchey SJ, Schonholtz GJ, Thompson MS. The dashboard femoral fracture. Pathomechanics, treatment and prevention. J Bone Joint Surg 1958;40(A):1347—58. P. Jain et al. 16. Shatzker J, Barrington TW. Fractures of the femoral neck associated with fractures of the same femoral shaft. Can J Surg 1968;11:297—305. 17. Swiontkowski MF, Hansen Jr ST, Kellam J. Ipsilateral fractures of the femoral neck and shaft: a treatment protocol. J Bone Joint Surg 1984;66(A):260—8. 18. Swiontkowski MF. Ipsilateral femoral shaft and hip fractures. Orthop Clin 1987;18(1). 19. Watson JT, Moed BR. Ipsilateral femoral neck and shaft fractures. Clin Orthop 2002;399:78—86. 20. Wiss DA, Sima W, Brien WW. Ipsilateral fractures of the femoral neck and shaft. J Orthop Trauma 1992;6:159—66. 21. Wolinsky PR, Johnson KD. Ipsilateral femoral neck and shaft fractures. Clin Orthop 1995;313:81—90. 22. Wu CC, Shih CH. Ipsilateral femoral neck and shaft fractures. Acta Orthop Scand 1991;62(4):346—51.