Trochanteric Nail Insertion Trochanteric Nail Insertion for the Treatment of for the Treatment of
Femoral Shaft FracturesFemoral Shaft Fractures
Journal of Orthopedic Trauma vol.19,8,Sep.2005
DR.ABDULRAHMAN ALGARNI
Introduction
1940,Kuntscher : tip of greater trochanter .
Late1940,Bohler: ridge of greater trochanter .
Winquist : lateral to GT.
Varus malalignment .
Eccentric reaming of medial cortex of proximal fragment .
Comminution at fracture site or both .
Advocated piriformis fossa (difficult;supine;obese) .
ObjectiveObjective
Using a nail especially designed for insertion
through G.T (TAN) could eliminate
complications seen with straight nails.
Materials and MethodsMaterials and Methods
Design and sitting : prospective; 3 trauma centers; 1 of 4 fellows .
Jan. 1 ,1999 and Dec. 31 ,2000 .
61 patients (14 – 97 yrs ) average (43.6) .
50 closed ; 11 open 5(1) , 2(3A) , 2(3B) .
11 obese (113 – 159 kg) ; 3 > 181 kg .
Intervention : supine ; TAN(cannulated,interlocking,Tit.).
13mm ; 7 cm ; 4 valgus bend.
Tip of GT,nail rotated 90 ;avoid iatrogenic complications .
52 reamed , 9 unreamed .All locked proximally and all but 4 distally .
ResultsResultsMain outcome measures : union , alignment,complications and hip function.
4 Pts died ;46 of 57 Pts (81%) for F\U at a Min. of 12 months .
UnionUnion
Clinical and radiographic, all but 1 at 13 weeks ,
1dynamisation at12 wks and united at 22 wks.
PT : once start WB .
AlignmentAlignment
Angulation(>10% in any plane or rotation>10)
:none;1 Pt shortening of 2cm .
ComplicationsComplications
No iatrogenic fractures or infections .
Heterotopic ossification :5 hips .
Pain : mild (6) ,moderate (2) .
Hip FunctionHip Function
24 Pts :Harris Hip Score 77 (45 – 96) .
Hip ROM :similar to normal side .
Visual & video taped gait analysis : 3 Trend. Gait .
DiscussionDiscussion
-Kuntscher :lateral;tip of GT; infection,AVN of femoral head and neck fractures .
-Bohler : top of GT .
-AO : lateral to avoid damage to retinacular vessels and hip joint .
-Straight nails through GT : comminution; varus esp. proximal fractures .
-Winquist :lateral ;switch to piriformis fossa
- Johanson : >6mm anterior to PF; increase risk of complications ; position evolved to
supine .
-Mc fee and Waddle : morbidly obese ;difficult in supine using
PF;increased risk of complications;accept more lateral starting
point .
- Ostrum :trochantric starting point; supine; satisfactory results in obese Pts .
-In this study;esp. nail and tip of GT .
-Marks et al : 21% risk of HO using PF; 15% in this study .
-Gait and abductor weakness : comparable to PF starting point .
ConclusionConclusionAntegrade femoral nailing in supine position using
specially designed nail inserted through tip of
greater trochanter provides high union rate and low
rate of complications including comminution and
angulation .
Thank youThank you