| Abstract|| |
Background : Fracture shaft femur is one of the most common fracture treated at tertiary level centre's requiring adequate radiological assistance. Providing distal locking zig arm support in the nail has made it possible to treat fracture shaft femur at primary level with acceptable locking, without the additional support of IITV with added benefits on surgeons part of less expertise, less surgery time, and good to excellent union rates and at the same time on patients part, avoidance of radiological exposure, being economical availability at the next door itself
Methods : One hundred and eight fractures of shaft of femora in 104 patients were treated at tertiary level with interlocking nails. Open nailing without IITV was done in 62 and closed nailing under IITV using proximal and distal locking zigs was done in 46 patients). All cases were operated within 24-48 hrs of injury. Results: The union rate at 12 months period was 93% in closed nails and 87.87% in open nails locked with distal zig averaging to 87% overall. Complications were the same as seen with closed interlocking nail involving limb length discrepancy malrotoation infection with added complication failure to lock distal end in few cases.
Conclusion : Benefits so derived from open interlocking of fracture long bones can be applied at the very basic level of Indian health infrastructure where the facilities of IITV and surgical expertise are still lacking. Considering the over increasing load of fracture long bones, the results are comparable to that of closed nailing and has benefits on surgeon and patients more suiting to the Indian health infrastructure
Keywords: Open interlocking nailing; Distal locking zig; Indian health scenario.
|How to cite this article:|
Meena R C, Kundnani V, Hussain Z. Fracture of the shaft of the femur : Close vs open interlocking nailing. Indian J Orthop 2006;40:243-6
| Introduction|| |
Close reduction and intramedullary fixation of fracture shaft femur proposed by Kuntscher, is the most biological way of treating the fracture shaft femur. But an open version of this procedure, by which the fracture is stabilized by opening the fracture site and fixing it by retrograde method, became popular because of less complication and more predictable operating time. With the development and emergence of image intensifier and modification in the technique, the locked intramedullary gained popularity. Locked intramedullary nailing can be inserted in a static or dynamic fashion,,,,,,,,.
Method of open nailing can be considered at rural health centres in Indian health scenario as comparably good results could be obtained with less expertise required and avoiding the radiological hazards and giving surgical assistance at a very economical basis. This additional benefit could be added by doing locking of the nail at proximal and distal levels with the help of distal locking zig arm without the help of IITV, without hampering the benefits of open nailing.
Keeping the multiple factors in mind e.g. overcrowded orthopedics wards with fracture femur, early disposal of the patient, less resources and unequipped peripheral hospitals (no facility of IITV and fracture table) and to avoid the hazards of radiation and various other benefits of open nailing, it was decided to conduct a study of open interlock nailing and its comparison with closed methods in fracture femur. Hence a plan was made to study the result of open-interlocking nail versus closed inter locking nail and it was practiced in 108 fracture of 104 patients.
| Material and methods|| |
The study was conducted in the year 2001 to 2005 on 104 pts aged more than 15yrs having 108 fracture of the shaft of the femur. After study of the X-ray, the fracture was classified according to the site, comminution and the nature of wound. Only 4 open fractures (grade I & II) were included the study. These 108 fractures were fixed within 2-3 days by intramedullary nailing (46 closed nailing, 62 open nailing) with locking done in both groups (46-underIITV support, 62with distal locking zig without IITV).
The length of the nail was measured from tips of the greater trochanter to the upper pole of patella, only 2 cm above and 2 cm below the measured size of nail were kept during surgery. The diameter of the nail was assessed according to the final reamer used at the time of surgery. The patient was fixed on the operating table (the normal limb was kept in full abduction to accomodate the 'c' arm of the image intensifier. The fractured limb was kept in adduction to make the greater trochanter more prominent and accessible. In all the cases closed manipulation under image control was done before draping to reduce the operating time.
We used static fixation in Winquist grade III and IV where there was severe comminution and the fracture was longitudinally and rotationally unstable, while dynamic locking fixation was used in grade I and II. IITV control was used in locking the closed nail whereas the locking in open nails was done by distal locking zig arm without IITV.
The insertion handle was used for the proximal locking with the help of protector sleeve and trocar through a separate incision. 4 mm self tapping screw was used for the same purpose. For locking distal end, the traction was released (in fracture grade I and II comminution) and the fracture was compressed. In grade III and IV of comminution, the traction was not released to prevent the collapse.
In open method the exposure of the fracture site was not different from standard procedure of K nail except insertion of guide rod which was inserted through fracture in a retrograde manner and by making a 4-5 cm long incision over the tip of greater trochanter. Open reduction of the fracture was done and guide rod was passed up to the supracondylar region. After removal of guide rod, with the help of insertion handle proximal locking was done in same way as in the closed nailing method with proximal locking zig arm.
Out of total 62 open interlocked nail, in 55 cases distal locking was done with the help of distal locking zig while in 7 cases it failed due to failed distal zig or misalignment of zig with distal femoral fragment or twisting of nail. These were locked under image intensifier the following day. The distal interlocking zig was mounted on the proximal end of the selected nail by conical bolt and tightened. The rotation and axis of the nail was checked with the position of the zig arm. By experience it was possible to make sure that axis and alignment of nail was parallel to the zig arm and all assembly was tightened snugly. The final status was checked under direct vision.
The zig arm has holes at different distances for distal static and dynamic locking corresponding to the nail size used. Through these holes, protection sleeve is inserted. Through a 2 cm incision on the distal thigh corresponding to the determined hole, sleeve was passed up to bone and then drilling was done with 4mm drill bit. Through the sleeve, screw size was measured and a proper size of 4 mm self tapping screws was inserted and tightened.
Post operative care & follow-up:
Static quadriceps exercise was started the next post operative day, suction drain was removed after 48 hours. After removal of sutures on 12th to 15th post operative day hip and knee bending exercises along with quadriceps drill was started. Partial weight bearing was allowed at 4 weeks.
Till the X-ray showed good callus formation, the patient was ambulating with the help of crutches. Gradually, one crutch was discarded and weight bearing with one crutch on opposite side was permitted for another 3 weeks. Full weight bearing was allowed on the radiological evidence of callus consolidation. The patients were followed at monthly intervals for 3 months regularly, then at 6th month, 9th month and finally at 12th month.
| Results|| |
Male to female ratio was 8: 1 and 77 patients were in the 3rd and 4th decades. The mode of injury in 91 cases was road traffic accident. Four fractures were open. According to the site of fracture, 16 were at proximal third, 54 at middle third and 38 were at distal third of femoral shaft. The union rate was 50/62 in open nailing and 42/46 was in closed nailing. The break up of union according to time is shown in [Table - 1].
The clinico radiological evaluation was done and the final observation where made according to the criteria by Mehrotra et al6. There was excellent result in 54.83% cases of open inter lock procedure and 65.21% in closed nailing procedure. Fair in 41.95% open and 34.21 % in closed. The complications which were noted are shown in [Table - 2].
Late interventions were done in 16 cases of open nailing and four cases of closed nailing. Bone grafting and dynamization was done in 6 cases of open interlock nail. In two open interlock cases, nail was broken; one was replaced by close nail and one left in situ because the union and callus formation was excellent. Dynamization was done in two cases of closed interlock nail.
| Discussion|| |
Since very old times various modalities of treatment have been suggested for treating fracture long bones. Closed nailing and closed interlocking were introduced after the advent of IITV. In India there are still very few centers having facility of IITV control, particularly at the basic level of health infrastructure, ours is a method targeting to that area of health system, so that the treatment of fracture shaft femur could be made available at the very next door of the victim of long bone fracture, at the rural health structure level.
The femur is the most commonly fractured long bone. It is undisputed that majority of these fractures can be satisfactorily treated by close inter locking nail. but in Indian health infrastructure particularly at rural centers where the facility of IITV, high surgical expertise are not available and referral centers are situated at long distances, it is not the method of choice and open nailing with proximal and distal locking with the help of distal locking zig arm should be considered as the modality to treat these fractures.
In all 87% fractures united in the present series in the period of observation, in open nailing 83.87 had united by 12 months. The earlier healing time with close nailing could be attributed to non disturbance of the fracture haematoma. Patiet al reported similar union rate. The poor result in our series is due to deep infection and satisfactory or fair are due to associated injury.
The time for union is a very controversial topic. It is not possible to assess healing of fracture by usual orthopaedic criteria. Since after operation, stability is obtained immediately and patient becomes pain free in the ensuring 3-4 weeks. Time to healing could not be assessed accurately either clinically or radio logically since such large intramedullary nails were used. Clawson et al have reported an average time for appearance of bridging callus at6 weeks with partial obliteration of fracture site as the time of union. Rockaen et al have used the time elapsing between the accident and ability to walk without stick and return to work as the criteria for the progress of fracture healing. In this study nature of bridging callus with partial obliteration of fracture site has been used as time for union. Assessment on return to work cannot be taken as a sign for progress of fracture healing since the majority of patients involved in the present series are usually heavy manual laborer who require solid union before they can go back to work in contrast to the western countries where patients usually have sedentary jobs and hence can be put to work earlier as compared to a manual laborer.
The open IL nailing with a predictable surgical time procedure is less expensive, easy and more convenient for less experienced newly qualified orthopaedic surgeon, only fewer instruments are required. Due to the direct observation of bone may lead to absolute anatomic reduction which can not be possible with close IL procedure particularly in comminuted and segmental fractures. In comparison to the closed method, rotational mal-alignment is rare after open reduction. In non unions opening of the medulary canals of the sclerotic bone is easier, and it required simultaneous bone grafting can be considered.
But surgical skin scar, increased blood loss, loss of fracture haematoma (which is more important in fracture healing) increased infection rate, and complication rate particularly in comminuted fracture and decreased rate of union has its own demerits in open IL nailing procedure.
Authors recommend modification in distal locking zig arm by means of providing intermediate arm support, in between the proximal and distal locking points to stabilize the free handing of zig arm, during the distal locking of open inter locking nail, as was the need in failed distal locking 12 cases.
| References|| |
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R C Meena
Department of Orthopaedics, SMS Medical College & Hospital, Jaipur
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1], [Table - 2]