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