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Failure of intertrochanteric nailing due to distal nail jamming.

Maniscalco P, Rivera F, D'Ascola J, Del Vecchio EO - J Orthop Traumatol (2012)

Bottom Line: Dynamic distal locking can be ineffective if the ability of the distal nail to slide within the diaphyseal canal is hindered.This type of scenario can represent an opportunity for anterior nail impingement.For these reasons, caution is recommended when using medium-length trochanteric nails for unstable trochanteric fractures.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Azienda Ospedaliera Piacenza, Via Taverna 49, Piacenza, Italy.

ABSTRACT
Nail impingement against the anterior femoral cortex during nail insertion, or anterior cortex penetration, has been described in the literature as a worrying complication. We describe a previously unreported surgical failure due to a compromised dynamic distal locking caused by distal jamming of the nail. An 80-year-old male suffered a closed right intertrochanteric femoral fracture. Due to the presence of a long medial fragment, a 240 mm long titanium trochanteric nail was chosen to stabilize the fracture. Dynamic distal locking was performed by placing the distal screw at the inferior rim of the elliptical locking hole to allow compression of the fracture site during weight-bearing. Six-month X-ray follow-up revealed a broken nail and nonunion of the fracture due to failed dynamization of the distal locking screw. The nail was removed and replaced by a total arthroplasty. Due to the femoral anterior bow of the shaft, anterior cortical impingement of the distal tip of a nail may result in the failure of the nail to slide within the diaphyseal canal when using a medium-length nail preventing compression of the fracture. Dynamic distal locking can be ineffective if the ability of the distal nail to slide within the diaphyseal canal is hindered. This type of scenario can represent an opportunity for anterior nail impingement. Distal jamming of the nail can thus compromise dynamic compression at the fracture site during loading, thus inducing nonunion of the fracture, and leading to breakage of the osteosynthesis device. For these reasons, caution is recommended when using medium-length trochanteric nails for unstable trochanteric fractures.

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Preoperative anteroposterior radiograph shows an AO-OTA 31-A2.2 hip fracture
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Fig1: Preoperative anteroposterior radiograph shows an AO-OTA 31-A2.2 hip fracture

Mentions: An 80-year-old male, 166 cm tall and weighing 56 kg, suffered a closed right intertrochanteric femoral fracture. X-rays in the emergency room revealed an unstable intertrochanteric fracture with more than two intermediate fragments (AO-OTA 31-A2.2 hip fracture) [10] (Fig. 1). Due to the presence of a long medial fragment, a 240 mm long titanium trochanteric nail (Endovis, Citieffe, Bologna, Italy) was chosen to stabilize the fracture (Fig. 2). Dynamic distal locking was performed by placing the distal screw at the inferior rim of the elliptical hole to allow compression on the fracture site during weight-bearing. Partial weight-bearing was allowed after 15 days. Postoperative X-rays at 1 month revealed nonunion of the fracture. The patient underwent monthly clinical and radiographical follow-up. Groin pain during walking and limping persisted during the following months. After 6 months, the patient had severe groin pain and some distal anterior thigh pain. X-rays revealed breakage of the nail and nonunion of the fracture due to failed proximal sliding of the distal screw within the distal elliptical locking hole (Fig. 3). During surgery, atrophic nonunion of the trochanteric fracture was observed. The nail was removed and replaced with a total hip arthroplasty combined with metallic cerclage around the distal fragment (Fig. 4). Two months after the hip replacement, the patient reported the disappearance of his groin pain.Fig. 1


Failure of intertrochanteric nailing due to distal nail jamming.

Maniscalco P, Rivera F, D'Ascola J, Del Vecchio EO - J Orthop Traumatol (2012)

Preoperative anteroposterior radiograph shows an AO-OTA 31-A2.2 hip fracture
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3585948&req=5

Fig1: Preoperative anteroposterior radiograph shows an AO-OTA 31-A2.2 hip fracture
Mentions: An 80-year-old male, 166 cm tall and weighing 56 kg, suffered a closed right intertrochanteric femoral fracture. X-rays in the emergency room revealed an unstable intertrochanteric fracture with more than two intermediate fragments (AO-OTA 31-A2.2 hip fracture) [10] (Fig. 1). Due to the presence of a long medial fragment, a 240 mm long titanium trochanteric nail (Endovis, Citieffe, Bologna, Italy) was chosen to stabilize the fracture (Fig. 2). Dynamic distal locking was performed by placing the distal screw at the inferior rim of the elliptical hole to allow compression on the fracture site during weight-bearing. Partial weight-bearing was allowed after 15 days. Postoperative X-rays at 1 month revealed nonunion of the fracture. The patient underwent monthly clinical and radiographical follow-up. Groin pain during walking and limping persisted during the following months. After 6 months, the patient had severe groin pain and some distal anterior thigh pain. X-rays revealed breakage of the nail and nonunion of the fracture due to failed proximal sliding of the distal screw within the distal elliptical locking hole (Fig. 3). During surgery, atrophic nonunion of the trochanteric fracture was observed. The nail was removed and replaced with a total hip arthroplasty combined with metallic cerclage around the distal fragment (Fig. 4). Two months after the hip replacement, the patient reported the disappearance of his groin pain.Fig. 1

Bottom Line: Dynamic distal locking can be ineffective if the ability of the distal nail to slide within the diaphyseal canal is hindered.This type of scenario can represent an opportunity for anterior nail impingement.For these reasons, caution is recommended when using medium-length trochanteric nails for unstable trochanteric fractures.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedic Surgery, Azienda Ospedaliera Piacenza, Via Taverna 49, Piacenza, Italy.

ABSTRACT
Nail impingement against the anterior femoral cortex during nail insertion, or anterior cortex penetration, has been described in the literature as a worrying complication. We describe a previously unreported surgical failure due to a compromised dynamic distal locking caused by distal jamming of the nail. An 80-year-old male suffered a closed right intertrochanteric femoral fracture. Due to the presence of a long medial fragment, a 240 mm long titanium trochanteric nail was chosen to stabilize the fracture. Dynamic distal locking was performed by placing the distal screw at the inferior rim of the elliptical locking hole to allow compression of the fracture site during weight-bearing. Six-month X-ray follow-up revealed a broken nail and nonunion of the fracture due to failed dynamization of the distal locking screw. The nail was removed and replaced by a total arthroplasty. Due to the femoral anterior bow of the shaft, anterior cortical impingement of the distal tip of a nail may result in the failure of the nail to slide within the diaphyseal canal when using a medium-length nail preventing compression of the fracture. Dynamic distal locking can be ineffective if the ability of the distal nail to slide within the diaphyseal canal is hindered. This type of scenario can represent an opportunity for anterior nail impingement. Distal jamming of the nail can thus compromise dynamic compression at the fracture site during loading, thus inducing nonunion of the fracture, and leading to breakage of the osteosynthesis device. For these reasons, caution is recommended when using medium-length trochanteric nails for unstable trochanteric fractures.

Show MeSH
Related in: MedlinePlus