| Abstract|| |
Background: Complex proximal femoral fractures are challenging problem.
Methods: Forty-one patients had Russell- Taylor Delta reconstruction nailing done during the period from March 1992 to December 1996. 38 patients could be followed both clinically and radiologically either up to the fracture union or death. Clinical outcome was assessed by Kyle's criteria. Out of 13 patients with high-energy comminuted fractures, 12 were rated excellent or good. There was one death due to poly trauma.
Results: Out of six elderly subtrochanteric fractures, 4 had excellent or good results. There was one poor result and one death. Out of 11 elderly interochanteric fractures with subtrochanteric extension, 8 had excellent or good results. There was 1 fair, 1 poor result and 1 death. In the elderly groups, the poor results were due to poor pre- existing medical conditions of the patients. In all the seven cases of pathological lesions, excellent or good results were achieved either till fracture union or death because of their malignant pathology.
Conclusion: Russell- Taylor Delta reconstruction nail is a very useful device in high-energy comminuted proximal femoral fractures, in elderly low energy proximal femoral fractures and also in pathological lesions. The implant provides bio-mechanically stable fixation. The relatively high complication rate in elderly patients is because of their poor medical condition. In cases of pathological lesions, it is always preferable to fix the bone at the stage of impending fracture.
Keywords: Russell- Taylor- Delta -reconstruction- Nail; Proximal femoral Fractures.
|How to cite this article:|
Raj D, Coleman N P. Role of Russell - Taylor delta reconstruction nail in the management of complex proximal femoral fractures. Indian J Orthop 2005;39:99-103
|How to cite this URL:|
Raj D, Coleman N P. Role of Russell - Taylor delta reconstruction nail in the management of complex proximal femoral fractures. Indian J Orthop [serial online] 2005 [cited 2019 Oct 15];39:99-103. Available from: http://www.ijoonline.com/text.asp?2005/39/2/99/36782
| Introduction|| |
Interlocking nail is an established treatment option for comminuted and complex femoral fractures , . Russell- Taylor Delta reconstruction nail (RTRN) allows for the treatment of complex fractures of the femur by combining two sliding screws for stabilisation of the femoral neck with distal locking capabilities. Distally, the reconstruction nail uses standard locking screws, which are fully threaded to ensure optimum bone purchase and to prevent backing out. The reconstruction system was designed with two overall goals for healing of long bone fractures. The first was to improve the clinical success of previously available interlocking nails by reducing complications. The second goal was to design an interlocking nail system that would be more acceptable for treating complex femoral fractures  .
A review of the use of RTRN was conducted to evaluate its efficacy in cases of complex femoral fractures.
| Patients and Methods|| |
Forty one patients suffering from complex femoral fractures, during the period from March 1992 to December 1996, were treated by RTRN. Fracture classification was done according to Seinsheimer  system [Table - 1]. The criterias for inclusion were:
- Intertrochanteric fracture with subtrochanteric extension
- Ipsilateral fracture neck and shaft of femur
- Subtrochanteric fracture of femur
- Subtrochanteric fracture with fracture shaft of femur
- Impending pathological subtrochanteric fracture of femur
- Pathological subtrochanteric fracture of femur
Preoperative planning was done to choose the proper implant size. Fracture table was used in all the cases. Image intensifier was used and the entry point was selected very carefully. In the first 11 cases, we did not routinely do static locking and also we used either one or two proximal screws. In the last 30 cases, routinely we did proximal and distal locking with two screws each. All the patients had prophylaxis against venous thromboembolism and infection.
We could follow-up 38 cases both clinically and radiologically either until fracture union or death. Three patients were lost in the study. Two 2 had moved and one
| Results|| |
We divided the patients into seven groups on the basis of
- Age of the patient
- Mode of injury
- Fracture pattern
- Pathological lesion (imminent fracture or complete fracture)
High energy comminuted fractures
There were 13 patients in this group, 12 males and one female. The mean age in this group was 38 years (range 18 - 59 years). All cases were involved in road - traffic accidents.
Only two of them had isolated fracture of the femur. Nine patients had polytrauma. One patient with polytrauma and head injury died 3 weeks after the fracture fixation in the intensive care unit (ICU). Two cases had open fractures. Fracture union took place in 18 weeks (average). Four patients had pain in the outer aspect of the proximal part of the thigh, which settled after removal of the proximal screws when the fracture had consolidated. One patient had delayed union of the fracture. He had an open very highly comminuted fracture (Seinsheimer grade V). He needed exchange nailing and bone grafting, after which sound union took place. In one case, the proximal screws backed out. It was causing pain and irritation to the fascia lata. His symptoms settled completely after removal of the screws one year after the operation. We did not routinely take out distal screws before permitting full weight bearing. Distal screws were removed only in those cases (3 femurs) after three months when there was evidence of slow fracture union radiologically and it was felt that dynamisation is needed to enhance fracture union. In one case, the distal screw broke approximately 14 weeks after the fracture fixation. We had put only one distal screw in this case. The patient was asymptomatic. After one and half years, when the implant was removed, the asymptomatic broken piece of screw was left inside. There was no evidence of infection or mal-union. The surviving 12 patients went back to their pre-fracture level of activity.
Elderly subtrochanteric fracture
In this group, there were 6 patients, one male and five females. The mean age was 83 years (range 76 - - 92 years). These were low energy injury following minor trauma. 5 out of the 6 patients had pre - existing pulmonary and or cardiovascular problems. One fracture required open reduction; the remaining five cases were treated by closed nailing. There were significant complications in four patients. One patient each developed non-fatal pulmonary embolism, cerebro-vascular accident leading to ipsilateral hemiplegia, one bad chest infection, and one massive myocardial infarction four days after the injury, who died in the coronary care unit. In one case, no distal locking was done. The fracture collapsed after six weeks. We had to take her back to theatre. Under anaesthesia, manipulation was done, good length was achieved and then distal locking was done using two screws. The fracture united uneventfully. There was no case of nonunion and infection in the femur. Four patients complained of pain in the outer aspect of the proximal part of the thigh, especially on rotation of the hip joint. The pain was bearable in two cases, but in the other two, the proximal screws had to be extracted after one year with good results in pain relief. We achieved excellent or good results in four and poor in one patient. There was one death.
Elderly intertrochanteric fracture with subtrochanteric extension
There were 11 patients in this group, two males and nine females. The mean age was 85 years (range 72 - - 91 years). These were low energy injury due to a fall or minor trauma. Significant medical problems were in 7 of the 11 patients. Open reduction was needed in two patients. One patient developed a massive congestive cardiac failure who ultimately died after two weeks. One patient developed myocardial infarction. Problem of proximal screw cut-out into the hip joint took place in two cases. In both cases, the position of proximal screws were not satisfactory, the screws were placed in the superior and anterior quadrants. In one case, only one of the two screws had cut through. The screw was taken out three weeks after the primary surgery. In another case, both the screws were noted to cut through two months after the primary operation. Both the screws were taken out. The fracture united without any problem. In one case, the proximal screws were very long. The patient was taken back to the theatre after two days and appropriate size screws were put in. There was no case of non - union. We achieved excellent and good results in eight cases, fair and poor results one each because of poor medical conditions and there was one death due to massive congestive cardiac failure.
Ipsilateral femoral neck and shaft fracture
There was one case of ipsilateral neck and shaft fracture. A 39 years old man as involved in a high velocity road-traffic accident. This patient had a Garden type III fracture neck of femur and a displaced fracture mid shaft of femur (AO type 32.C3). He also had a contralateral fracture shaft of tibia. The femoral fracture was fixed with a RTRN. In the same sitting, the fracture tibia was fixed with a static nail. Post-operative recovery was satisfactory. He complained of pain over the proximal screw site and rotation of the hip was painful. The fracture union took place in 16 weeks. When the implant was removed along with the proximal screws after 18 months, his pain disappeared. He ultimately got the pre-injury activity level.
Pathological fracture - Benign lesion
There were two male patients. Both had Paget's disease. In one case, 3 months post fracture fixation with RTRN, radiologically, there was minimal callus formation around the fracture site. The distal screws were extracted, the nail was dynamised and full weight bearing was allowed. He needed exchange nailing after six months. The fracture ultimately united. There was one excellent and one good result.
Pathological fracture - Malignant lesion
There were 3 pathological fractures, two females and one male. The mean age was 69 years (range 59-78 years). The primary lesions were carcinoma of breast, lung and kidney, one each. All patients were able to mobilise pain free after the fracture fixation. There was no technical complication. One patient died four weeks after the surgery, the second one died after six months and the third patient died after two years, all because of their malignant condition. We achieved good results in all of them.
Imminent fracture - Malignant lesion
Two patients presented with incipient fracture following a malignant metastatic deposit, one male and one female. The mean age was 75 years (range 72 - - 78 years). The primary neoplasm was multiple myeloma and carcinoma of prostate. In one case, the lesion was localised to the subtrochanteric region. This patient had a proximal screw cut out into the hip joint, three months after the surgery. He was taken back to the operating theatre. The screw was extracted. The other of the two proximal screws, which was well in the neck and head of femur, was left in- situ. The second case had presented with two lesions, one in the subtrochanteric region and the other in the supracondylar region [Figure - 1]. Both the patients were pain-free and mobile until death after fixtion with RTRN.
| Discussion|| |
In this series, overall excellent to good results were achieved in 32 patients (84%). This compares favorably with the results of Bergman et al  . He reported results of 131 patients, treated with Zickel device with overall satisfactory outcome in 90% of cases.
RTRN gave good results in young patients with high energy comminuted fractures. All patients except one (polytrauma), who died because of a major head injury were able to go back to pre-injury level rapidly. Gibbons et al  produced similar reports in their series. Bose et al  reported high complication rate after Russell Taylor reconstruction nail. In their series of 11 patients (six comminuted subtrochanteric and five ipsilateral neck and shaft fractures), there were two delayed unions, two shortening of the femur, one malalignment and three technical errors during surgery leading to fracture complication. In our study, 13 patients had high-energy comminuted sub-trochanteric fractures and one patient had ipsilateral neck and shaft fracture due to high-energy road traffic accident. There was one case of delayed union in the high-energy group, who needed bone grafting. 5 patients complained of pain in the outer aspect of the proximal part of the thigh, which settled after removal of the implant. Proximal screw backed out in one case and distal screw broke in one case.
Seventeen elderly patients (6 subtrochanteric fracture and 11 inter-trochanteric fracture with subtrochanteric extension) had this implant. This implant provided a good stabilization. There were significant medical complications. There was one mechanical failure due to technical error. In this case, a comminuted subtrochanteric fracture, distal locking was not done. After six weeks the fracture collapsed with further comminution. After static locking, the problem was solved. We feel that it is mandatory to do static locking in each case. 4 cases in this group also complained of pain in the outer aspect of the proximal part of the thigh.
All the 7 cases of pathological lesions (2 benign lesions, 3 subtrochanteric fractures and 2 imminent fractures due to secondary deposit) the implant served its purpose. All the patients were comfortable, ambulant and comparatively pain free after the operation. One case had a proximal screw cut out because of technical error. There was one delayed union. This concurs with the findings of Gibbons et al  . This result is superior to extramedullary fixation device used for fixation of this kind of fracture. Weikert et al  reported an experience of 11 cases, who had Russell Taylor reconstruction nailing done for impending pathological fracture in the subtrochanteric region. They concluded that this implant has definite advantage for treating these lesions. Yazawa et al  reported 23% rate of implant failure in proximal femoral pathological fractures treated with compression screw or nail plate fixation.
Insertion of RTRN is technically demanding  . We experienced several problems initially. Nine cases presented with problems of pain in the outer aspect of proximal part of the thigh. The design of RTRN nail is such that the two proximal screw heads are outside the bone. The proximal screws head seems to irritate the fascia lata. On rotation of the hip, these patients complain of pain. In this series, the problem resolved once the proximal screws were removed after the fracture union. It is essential to do static locking. If distal locking is not done, the fracture might collapse. Distal locking should always be done with two screws. There was one distal screw breakage in this series, where distal locking was done with only one screw. Two proximal screws are essential. The chances of migration of screws are less if two proximal screws are placed. The distal of the two proximal screws should be placed just above the calcar. This allows proper placement of both screws in the neck and head of femur with good hold. In coronal plane, both screws should be in the central axis of the neck and head of the femur [Figure - 2]. The tips of the screws should be approximately within 10mm of the articular surface of the head of femur. Correct entry point is absolutely essential to get good results , . If the entry point is posterior, the implant may cut out distally, especially in osteoporotic bone. If the entry point is medial or lateral, further iatrogenic comminution may be created during insertion of the nail. Tissue respect is of paramount importance. We achieved closed reduction in 33 cases. Out of five patients, who had open reduction, two were open fractures. Two patients of delayed union who needed bone grafting had open reduction of the fracture done initially. We feel that closed reduction has definite advantages. It minimizes the incidence of infection and also iatrogenic injury to the soft tissue hence provides rapid recovery.
| References|| |
|1.||Johnson KD, Johnston DW, Parker B. Comminuted femoral-shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail. J Bone Joint Surg (Am). 1984; 66: 1222-35. |
|2.||Wu C, Shih C, Ueng W, Chen Y. Treatment of segmental femoral shaft fractures. Clin Orthop. 1993;287:224-30. |
|3.||Russell TA, Taylor JC, LaVelle DG. The Smith & Nephew Richards family of reconstruction interlocking nails: Surgical technique. 1987;3-4. |
|4.|| Seinsheimer F. Subtrochanteric ftactures of the femur. J Bone Joint Surg (Am). 1978;60: 300-6. |
|5.||Kyle RF, Gustilo RB. Analysis of six hundred and twenty-two intertro chanteric hip fractures. J Bone Joint Surg (Am). 1979;61:216-21. |
|6.||Bergman GD, Winquist RA, Mayo KA, Hansen ST Jr. Subtrochanteric fracture of the femur: Fixation using the Zickel nail. J Bone Joint Surg ( Am). 1987; 69: 1032-40. |
|7.||Gibbons CL, Gregg-Smith SI, Carrell TW, Murray DW, Simpson AH. Use of the Russell-Taylor reconstruction nail in femoral shaft fractures. Injury. 1995; 26: 389-92. |
|8.||Bose WJ, Corces A, Anderson LD. A preliminary experience with the Russell- Taylor reconstruction nail for complex femoral fractures. J Trauma. 1992;32: 71-6. |
|9.||Weikert DR, Schwartz HS. Intramedullary nailing for impending pathological subtrochanteric fractures. J Bone Joint Surg (Br). 1991;73:66870. |
|10.||Yazawa Y, Frassica FJ, Chao EY, Pritchard DJ, Sim FH, Shives TC. Metastatic bone disease. A study of surgical treatment of 166 pathological humeral and femoral fractures. Clin Orthop. 1990; 251:213-9. |
|11.||Coleman NP, Greenough CG, Warren PJ , Clark DW, Burnett R. Technical aspects of the use of Russell Taylor reconstruction nailhe use of Russell-Taylor reconstruction nail. Injury. 1991;22: 89-92. |
|12.||Russell TA. Biomechanical concepts of femoral intramedullary nailing. Int J Orthop Trauma. 1991;1: 35-51. |
10 Notton Way, Reading, Berkshire RG6 4AJ, England
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2]