|Year : 2018 | Volume
| Issue : 1 | Page : 22-26
Role of reconstruction intramedullary nailing in the treatment of ipsilateral femoral neck and shaft fractures
Sohail Ahmad, Ziaul Hoda Shaan, Mohd Faizan, Latif Zafar Jilani, Naiyer Asif, Mazhar Abbas
Department of Orthopaedic Surgery, J.N. Medical College, A.M.U, Aligarh, Uttar Pradesh, Department of Orthopaedic Surgery, J.N. Medical College, A.M.U, Aligarh, Uttar Pradesh, India
|Date of Web Publication||15-Feb-2018|
Ziaul Hoda Shaan
Department of Orthopaedic Surgery, J.N. Medical College, AMU, Aligarh - 202 002, Uttar Pradesh
Background: Ipsilateral femoral neck and shaft fractures are an uncommon injury, and many a times, femoral neck fracture is missed initially making treatment of these fractures a challenge to the treating surgeon. Still controversy exists regarding which technique and implant provide optimal treatment of these complex injuries. The purpose of this study was to evaluate the results of ipsilateral femoral neck and shaft fractures treated with reconstruction intramedullary nailing.
Materials and Methods: Eighteen patients having ipsilateral femoral neck and shaft fractures were included in this study. One patient was having bilateral involvement. All the patients were treated by close reduction and internal fixation with reconstruction intramedullary nailing. Average follow-up period was 3.5 years (range 2–8 years).
Results: According to Friedman–Wayman criteria, the outcome was good in 14 (77.8%), fair in 3 (16.7%), and poor in 1 (5.5%) patient. Femoral shaft fracture in one patient who was having bilateral involvement went into nonunion which required revision nailing with antegrade femoral interlocking nail.
Conclusion: The treatment of these injuries with reconstruction intramedullary nailing is advantageous in terms of possible close antegrade nailing with minimal surgical trauma, reduced blood loss, less incidence of infection, and biological fixation of both fractures with a single implant.
الخلفية: العنق الفخذي وكسور رمح هي إصابة بنفس الجهة غير مألوفة، وكثيرا ما غاب كسر الرقبة في البداية مما يجعل علاج هذه الكسور تحديا للجراح المعالج. ولا يزال هناك جدل حول أي وسيلة علاجية او وزرع يوفر العلاج الأمثل لهذه الإصابات المعقدة. وكان الغرض من هذه الدراسة تقييم نتائج علاج كسر رقبة ورمح الفخذ وبنفس الجهة بواسطة اعادة التعمير بالتسمير داخل النقي.
المواد والطرق: تم تضمين ثمانية عشر مريضا لديهم كسور رقبة ورمح الفخذ بنفس الجهة الدراسة. وكان أحد المرضى يعاني من مشاركة ثنائية. تم علاج جميع المرضى عن طريق خفض وثيق والتثبيت الداخلي مع اعادة التعمير بالتسمير داخل النقي. وكان متوسط فترة المتابعة 3.5 سنوات (المدى 2-8 سنوات).
النتائج: وفقا لمعايير فريدمان-وايمان، كانت النتيجة جيدة في 14 (77.8٪)، متوسطة في 3 (16.7٪)، وضعيفة في 1 (5.5٪) من لمرضى. كسر رمح الفخذ في مريض واحد الذي كان يعانى من كسر بالجانبين لم يتحد الكسر لديه تتطلب ذلك مراجعة تسمير مع بمسامير متشابكة.
الخلاصة: علاج هذه الإصابات مع اعادة التعمير بالتسمير داخل النقي هو مفيد من حيث بممكن وثيق مع الحد الأدنى من التلف الجراحية، وانخفاض فقدان الدم، وأقل وقوعا للعدوى، والتثبيت البيولوجي لكلا الكسور مع زرع واحد.
Keywords: Ipsilateral, femoral shaft and neck fractures, reconstruction nail
|How to cite this article:|
Ahmad S, Shaan ZH, Faizan M, Jilani LZ, Asif N, Abbas M. Role of reconstruction intramedullary nailing in the treatment of ipsilateral femoral neck and shaft fractures. Saudi J Sports Med 2018;18:22-6
|How to cite this URL:|
Ahmad S, Shaan ZH, Faizan M, Jilani LZ, Asif N, Abbas M. Role of reconstruction intramedullary nailing in the treatment of ipsilateral femoral neck and shaft fractures. Saudi J Sports Med [serial online] 2018 [cited 2019 Aug 24];18:22-6. Available from: http://www.sjosm.org/text.asp?2018/18/1/22/225296
| Introduction|| |
Ipsilateral femoral neck and shaft fractures are an uncommon injury pattern, occurring in 2% to 6% of all femoral shaft fractures., The pattern of injury presents a challenge to the treating orthopedic surgeon. Complications such as avascular necrosis (AVN) of femoral head, nonunion, malunion, and fat embolism are frequent complications encountered during management. The associated injury pattern was initially described in 1953. Since then, approximately 300 instances of this injury have been reported in the literature, and more than 60 treatment alternatives have been described. Injury generally is a result of high-velocity trauma with the patients being relatively young with an average age of 34.6 years.,, Multisystem injuries occurred in 73% to 100% of patients.,,, The femoral shaft fracture is usually in the middle third, and neck fracture is basilar, vertically oriented, and minimally displaced. Initially, 41.7% of femoral neck fractures remained undiagnosed but after 1974 (the year the first review article on this injury was published), this has reduced to 11% in various cases reported since then due to increased awareness, better radiographic assessment, and management protocols.,,,
The timing of surgery, implant selection, and what sequence of fixation to be followed need to be taken into consideration. Although various implants have been used, no consensus has been achieved regarding the best and optimum treatment procedure. The selected implant should provide a stable and anatomic fracture reduction that would provide early mobilization of patient and high-union rates with reduced complications., The use of a single cephalomedullary nail has been advocated based on the ease of application and decreased surgical time and blood loss., Although there are reports which show that the use of two separate implant for individual fracture provides better result in terms of fracture reduction and complication rates.,
The purpose of this study is to provide the result of fixation of ipsilateral femoral neck and shaft fractures using reconstruction intramedullary nail as fixation device.
| Materials and Methods|| |
The study was prospective in nature, conducted between January 2006 and December 2015 and included patients presenting with ipsilateral femoral neck and shaft fractures to our orthopedic Emergency Department. All patients sustained an injury in high-velocity road traffic accidents. Patients having open injuries or those requiring open reduction were excluded from our study. A total of 18 patients were included in our study with 17 patients having unilateral injury while one had bilateral injury. Therefore, total of 19 femoral shaft and neck fracture were evaluated. There were 15 male and 3 female patients with a mean age of 36 years (range 20–55 years). The mean delay of presentation from the time of sustaining injury was 3.2 days (range 1–8 days). Moreover, the mean delay in operation was 6 days (range 4–10 days). There were no other associated injuries or comorbidities in any of the patient.
Plain radiographs of pelvis including both hips anteroposterior as well as radiographs of whole thigh anteroposterior and lateral view were taken. After necessary initial resuscitation, surgical management was done. Patients were mounted on traction table, and closed reduction was achieved under image intensifier with the limb being in slight abduction and internal rotation. The reconstruction nail was inserted through a lateral entry point made through lateral cortex just distal to the tip of greater trochanter. Reaming was performed under strict image intensifier monitoring so that the reduction of neck fracture was maintained. Proximal screws were inserted under image intensifier control, followed by the distal locking [Figure 1] and [Figure 2].
|Figure 1: (a and b) Radiograph of a 30-year-old male with ipsilateral femoral neck and shaft fracture. (c) Immediate postoperative fixation of fractures using reconstruction intramedullary nail. (d and e) Follow-up X-rays after 1 and 3 years of operation. Showing union at both neck and shaft fracture sites|
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|Figure 2: (a and b) Ipsilateral fracture neck and shaft of femur in a 28-year male patient (yellow arrows). (c) Immediate postoperative X-ray with gap present at neck fracture (red arrow). (d and e) Two years postoperative X-ray with union at both the neck and femoral shaft fracture sites|
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Patients were mobilized early that is active quadriceps drill, knee physiotherapy, and nonweight-bearing walk was started from the second postoperative day with the aid of axillary crutches. Partial weight-bearing was started when the signs of callus formation were seen on the radiographs in subsequent follow-ups. The radiological union was said to have occurred when bridging trabeculae appeared across fracture site at the neck region and callus with density similar to cortex was found connecting both fracture fragments of shaft femur. The fracture was said to be in nonunion when it did not heal at the end of 1 year of treatment or the one which required secondary surgery for achieving union.
| Results|| |
All femoral shaft and neck fracture united except in one patient whose femoral shaft went into nonunion and in another neck femur fracture went into nonunion. The mean duration of surgery was 140 ± 15 min. The mean follow-up was 3.5 years (range 2–8 years). Average union time for femoral neck fracture was 20 weeks and average union time for the femoral shaft fracture was 24 weeks. Femoral shaft fracture in one patient who was having bilateral involvement went into nonunion, which required revision nailing with femoral interlocking nail [Figure 3]. Neck fracture in one patient went into nonunion for this, nail was removed after shaft united, and neck fracture was fixed with 2 (7.0 mm) cannulated cancellous screws along with fibular strut grafting. This fracture united after 6 months. None of the cases went into AVN of the femoral head till the last follow-up. Based on Friedman-Wyman criteria, the outcome was Good in 14 (77.8%), Fair in 3 (16.7%), and poor in 1 (5.5%) patient [Table 1] and [Table 2]. Data comprising of femur shaft fracture pattern and level are given in [Table 3] and [Table 4], respectively.
|Figure 3: (a and b) Bilateral fracture neck and shaft femur fracture in a 35-year female (orange arrows); (c-e) Immediate postoperative X-ray right femur and right hip anteroposterior and lateral view of right side (c and d respectively), while Figure 3e shows that of left side. (f-h) Three months postoperative X-ray with gap present at right femoral shaft fracture site. (i-k) Nine months postoperative X-ray showing lag screw back out on right side with gap still present at right femur shaft fracture hence dynamization of distal screws were done on the right side while union can be seen progressing at both neck and shaft fracture site on left side. (l) Lag screw removed on the right side after 11 months postoperative (m and n) Exchange nailing done on the right side 12 months post operatively as the shaft femur went into nonunion. (o-q) Three years postoperative X-rays of the patient showing union at bilateral femoral neck and shaft fracture sites|
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|Table 3: Winquist classification of femoral shaft fracture used to classify patients|
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| Discussion|| |
Through this case series, we have shown the result of reconstruction intramedullary nail used for treating ipsilateral femoral shaft and neck fractures. In our study, 95% of the patients had good to fair result. The development this cephalomedullary nail has provided the advantage of an all-in-one device. The advantages being shorter operative time, single positioning, reduced blood loss through a single incision, and the biomechanical benefits of using a nail for the shaft fracture. A variety of fixation methods have been recommended to date; these include multiple flexible Ender nails with supplementary pinning, varying combinations of retrograde nailing or plate fixation for femoral shaft and for neck fractures dynamic hip screw or cannulated screw fixation, antegrade interlocking nailing with screw neck fixation. However, the optimal treatment protocol remains controversial.
With the use of reconstruction nail problems, such as knee pain and stiffness from retrograde nailing or extensive dissection and stress shielding for plate fixation are avoided. In addition, reconstruction nailing presumably avoids the technical difficulties of placing supplemental screws to stabilize the femoral neck in the presence of a standard femoral nail. However, the procedure is technically demanding. Nail insertion may cause further displacement of an undisplaced or minimally displaced femoral neck fracture, which then may be difficult to reduce. Importantly, difficulties have been reported in obtaining rotational alignment of the fractures as well as in achieving correct positioning of the proximal interlocking screws.
The neck fracture is most commonly missed (incidence ranging between 13% and 30%)., The most common reasons for the neck fracture to be missed include inadequate radiographic imaging, minimal displacement of the neck fracture, and the presence of other orthopedic or life-threatening injuries. This can be minimized by being vigilant and aware of this injury pattern and the routine use of pelvic and hip joint radiographs on admission according to the ATLS protocol.
Whether to use a single or two separate devices for the fixation of this combination of fractures is still the matter of debate. Tsai et al. found no significant difference in the amount of blood loss, duration of surgery, complications, or clinical results but identified an 11-fold less complication rate in the group of antegrade nailing with cannulated screw fixation of the neck fracture compared with the DHS with LCDCP group. Bedi et al. found that internal fixation of the neck fracture followed by retrograde nailing of the shaft fracture led to more accurate reduction and improved union rates compared with a single cephalomedullary device.
The complications associated with the surgical management of this pattern of injury include AVN of the femoral head, nonunion, or delayed union of fracture, malunion, fat or pulmonary embolism, and infection. The prevalence of AVN ranges between 3% and 4% in most reported series. Nonunion of the femoral neck fracture occurs in approximately 5%. Bose et al. treated five patients with ipsilateral femoral neck and shaft fractures on a delayed basis. Varus malunion of the femoral neck attributable to technical error in inserting the reconstruction nail developed in only one of the five. However, the authors described the use of the reconstruction nail as technically difficult in this setting.
Femoral shaft nonunion or delayed union, in comparison, is more likely. Jain et al. reported a 20% incidence of femoral shaft nonunion using reconstruction nailing. Vidyadhara and Rao  reported delayed union of the shaft fracture in 22 out of 43 patients. In our study, one patient who was having bilateral involvement went into nonunion which required revision nailing with femoral interlocking nail.
However, the limitations of our study are the number of patients examined, and no comparison was made between different fixation techniques. To conclude, ipsilateral femoral neck and shaft fractures are uncommon but potentially devastating injuries. Our study lends ample support for the use of reconstruction nail as a fixation device for ipsilateral femoral neck and shaft fractures. Although there is still, the need for larger prospective comparison studies using cephalomedullary nailing and the use of combination of implants for fixing these fractures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]