| Abstract|| |
Background: Ipsilateral fractures of shaft and neck of femur pose a problem of missed diagnosis and management.
Method: Forty eight patients of ipsilateral femoral shaft and neck fractures were treated by closed reduction and fixation by Gamma nail. Patients were followed for average period of 48 months.
Results: Six femoral shafts and two femoral necks had isolated non unions while one patient had nonunion at both sites. Varus malunion with resultant shortening was seen in six patients.
Conclusion: Gamma nail is a good implant to treat ipsilateral fractures of shaft and neck of femur.
Keywords: Gamma nail; ipsilateral femoral shaft and neck fractures.
|How to cite this article:|
Babhulkar S, Babhulkar S. Gamma nail in treatment of ipsilateral fracture of shaft and neck of the femur. Indian J Orthop 2005;39:104-7
| Introduction|| |
This unusual combination of fractures is seen in patients involved in high velocity injuries ,,, . Attention can easily be drawn to the more dramatic shaft fractures, while the possibility of another fracture in the same femur is not considered, thus missed. Despite advances in internal fixation methods ipsilateral femoral neck and shaft fractures continue to create dilemma in traumatologists minds so as to choose the best option amongst internal fixation devices and the timing of surgery.
Both the fractures of the femoral neck and fractures of the femoral shaft are independently common but to find a combination of these together is still not so common (2% to 6% of all femoral shaft fractures) , . Very few studies have been reported on this injury ,,,,,, . In recent years the number of these fractures may be increasing for two reasons: better recognition of this injury pattern and improved resuscitation leading to more survivors following high velocity trauma , .
| Method and materials|| |
We report a prospective, controlled study of 48 consecutive combined injuries of neck and shaft femur treated by a single method over a period of 8 years from January 1993 to December 2001, followed up for 2 to 8 years.
Fifty-four cases of ipsilateral neck and shaft femur fractures were identified between January 1993 and December 2001. Patients were seen at regular intervals of 1 month, 3 months, 6 months and then annually for clinical examination, follow-up X-rays. Six patients were lost to follow up evaluation before one year after injury and therefore were excluded from the study. Forty-eight patients were followed for an average follow up of 48 months (range 12-16 months). Thirty were followed for at least 4 years. All 48 were followed to union or established nonunion. There were 42 men and 6 women with an average age of 30 years (range 14 to 50 years). All injuries were a resultant of high energy trauma. Thirty-one patients were injured in motor vehicle accident while riding a twowheeler, 5 patients had a fall from a height of more than 3 storied building, 2 patients were victims of hit and run injury by a heavy vehicle.
Amongst this combination injury in twenty patients the femoral shaft fracture was comminuted. Five patients had subcapital fracture, seven had transcervical fracture, three had basal fracture neck femur, whereas twenty two patients had intertrochanteric fracture and eleven had subtrochanteric proximal femoral fractures. The alignment and position of the implants was assessed radiographically in AP and lateral planes. Data was reviewed to determine whether there was any consistent pattern of surgical error, implant failure, fracture characteristic and patient performance. All the patients were evaluated for date out of bed to chair, state of ambulation, ambulatory status at discharge, requirements for ambulatory assistance devices, weight bearing status at discharge, and length of the hospital stay. During each subsequent follow up visit the ambulatory status was assessed to include the need for assistance, devices, weight bearing status, pain on weight bearing. Radiographic analysis provided information on the fracture fragment position, lag screw position, nail alignment, and the extent of fracture healing.
All the patients were given spinal anesthesia. They were placed in a supine position on a fracture table. The procedure was carried out under image intensifier. Preoperative planning for rough assessment of the size of nail, size of hip screw was templated on AP and lateral radiographs.
Minimal traction was applied. Closed manipulation was barely required. The incision was approximately 3 inches in length based at the greater trochanter. In no patient open reduction was required.
The entry site for gamma nail is the tip of greater trochanter. If fracture line extended to this region guide wire was passed through the fracture cleavage plane without much of difficulty. Curved awl was used to prepare the entry hole; more recently we have used a cannulated curved awl for this purpose. Once guide wire was passed intra-medullarly, to judge femoral neck anteversion wire was placed and anteriorly a Steinman pin was passed to temporarily stabilize the femoral head reduction during subsequent reaming procedure. In cases where fracture line approached the trochantreric region, carefully sharp reamers were initially used to create a track for sequential blunt reaming. Final reaming was done at least 2 mm oversize. Nail was then passed manually. No hammering must be done as the fracture neck of femur is liable to get displaced.
The length of the compression hip screw was determined to reach up to a maximum of 2 mm less of subchondral articular surface or less, if good purchase is to be obtained in the femoral head. Distal interlocking was done by using fluoroscopy blind method and employing two interlocking bolts.
| Results|| |
All 48 patients were followed to union or established nonunion. There were 6 isolated femoral shaft nonunions and 2 isolated femoral neck nonunions. There was one patient of combined shaft and neck nonunion. All these underwent operative intervention and resulted in satisfactory outcome.
Two of three neck nonunions had a significant varus malalignment and were treated successfully with valgus intertrochanteric osteotomy using hip screw. The third nonunion of femoral neck was treated by revision with multiple cancellous screws. Out of three nonunions of neck femur, two had displaced transcervical fracture of neck of femur and one patient had basal fracture neck femur. All the femur nonunions were treated by over reaming and exchange nailing. Amongst femoral shaft nonunions four patients had severely comminuted fractures, whereas in two patients the fracture shaft of femur was in lower third with comparatively loose fitting interlocking nail. None required any open procedure of bone grafting. All healed well at the end of an average of 3 months.
Six patients had significant varus malunion with shortening but progressed to good union. One of them was operated for correction of varus deformity. Others (5/6) were advised for correction of deformity mainly to correct the shortening and the lurch but they refused to undergo any additional surgical intervention and accepted the deformity and used compensation shoes.
There was one superficial infection but it did not alter or modify the final outcome. There were no operative complications. At an average of 3 years follow up, the fractures in all the patients had healed and no patients were being treated. Functional outcome was significantly better if there was no concomitant polytrauma injury to the patient.
| Discussion|| |
Variable rates of success have been reported for this complex injury using reconstruction type nails with complications rates as high as 35 %. This is relatively not a frequently encountered injury and literature is still not abundant. Bernett et al reported on 42 cases over a 15 year period and Bose at al treated 5 cases in a 2 year period , .
The associated injury pattern was first described by Delaney and Street . Since then, approximately 300 instances of this injury have been reported in the literature, and more than 60 treatment alternatives have been described ,,,,,,,,. This injury pattern actually occurs in a patient with high energy trauma, with multiple injuries  . The more obvious Femoral shaft fractures gets attention first and immediate while patients with head injury or unconscious cannot report hip pain ; Those who are awake may have their hip pain masked by the pain of the shaft fractures; and many fractures are nondisplaced or minimally displaced.
Conventional teaching indicates that the femoral neck fracture potentially is the more problematic part of this injury  . However Alho, Watson and Moed , have suggested that femoral shaft fracture was the main determining factor of the patients' overall outcome. In the study of Watson and Moed the patients with femoral shaft nonunions required more operative procedures to achieve union when compared with patients with femoral neck nonunions. We agree with other investigators that the complications involving the shaft fracture of this injury pattern are not uncommon , . However, the shaft portion of this injury may not receive attention on priority the thought being as usual the shaft femur fracture will be easier to handle , .
In all the nonunion of fracture shaft femur cases (6 nos) the consistent finding was the undersizing of the shaft component of the nail in comparison with the medullary canal diameters, as frequently occurs with the unreamed technique of the intramedullary nailing.
Weight bearing was delayed after surgery especially to protect the fracture neck of the femur. In most of the cases it was begun at an average of 10 weeks from the initial surgery. Early progression to weight bearing facilitates callus formation and fracture union. The delay in weight bearing ambulation may have detrimental effect on those who were treated with undersized, less stable nail. All nails were passed after reaming of diaphysis of femur and no unreamed nails were used in our series. We agree with other investigators that larger, appropriately fitting reamed nail may be more effective, to achieve the benefit of early weight bearing to promote fracture healing.
In some of our cases wherein varus was encountered at the trochanteric level, patients were taken in operating room again to readjust the neck shaft angle and it was achieved by simply removing the hip screw and after adequate traction and abduction passing it again (3 cases). After assessment it was found that the lateral entry of nail and adduction during passage of nail are the factors responsible for the varus malalignment. All the patients resulted in good union at both the fracture sites. In 6 patients we encountered varus malunion. One of them underwent corrective valgus osteotomy. Others were advised the same for correction of limb length discrepancy and lurch. But, the patients choose not to undergo second surgery and decided to accept the deformity and shortening.
Gamma nail is a versatile implant and has the efficacy to handle this complex injury pattern. Though it bears a distinct disadvantage of steep learning curve, once surgeon and his team get used to the surgical technique this can prove to be a unique implant for handling this difficult clinical situation with good reproducible outcome
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Indira Gandhi Medical College and Sushrut Hospital, Research Centre & Post-Graduate Instt of Orthopaedics, Nagpur
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3]